|ORIGINAL RESEARCH REPORT
|Year : 2021 | Volume
| Issue : 2 | Page : 109-112
Ranula: A retrospective clinicosurgical analysis of 29 cases from a tertiary health institution, Northwest, Nigeria
Mohammed Abdullahi1, Abdurrazaq Olanrewaju Taiwo2, Kurfre Roberts Iseh1, Stanley Baba Amutta1
1 Department of Otorhinolaryngology, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
2 Department of Dental and Maxillofacial Surgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
|Date of Submission||24-Jun-2020|
|Date of Acceptance||24-Sep-2020|
|Date of Web Publication||24-Apr-2021|
Dr. Mohammed Abdullahi
Department of Otorhinolaryngology, Usmanu Danfodiyo University Teaching Hospital, Sokoto
Source of Support: None, Conflict of Interest: None
Background: Ranula may grow into a considerable size as to cause obstructive symptoms, especially in infants when neglected. The aim is to describe the clinical presentation, treatment, and outcome of ranulas. Methods: This is a retrospective study of patients with ranulas that presented during the periods of January 2000 to December 2019 in the Department of Otorhinolaryngology, Dental and Maxillofacial Surgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Northwest, Nigeria. Results: A total of 29 patients were seen during the review period: twelve (41.4%) males and 17 (58.6%) females. Age ranged from 3 days to 48 years (median 3 years). Most of the patients 19 (65.5%) were below the age of 10 years. Twenty-one (72.4%) patients had simple oral ranulas: 8 (38.1.6%) patients were congenital ranulas characterized by tongue protrusion and dysphagia. Plunging ranulas were seen in 8 (27.5%) patients, and 2 (25%) of these patients were HIV infected. Simple marsupialization was done for 10 (34.5%) patients, and one of these patients had an elective tracheostomy for difficult intubation. Sublingual gland excision and with the evacuation of the cyst were done for 16 (55.2%) patients. One of the patients with plunging ranula opted for conservative management. Only 12 (41.4%) patients came for follow up: a patient had recurrence 2 years after excision of plunging ranula. Conclusion: Ranula, when neglected can cause obstructive symptoms presenting as tongue protrusion in children. Inadequate follow up was seen in the majority of the patients. Adequate follow up to determine the recurrence, especially those who had marsupialization, is most desirable.
Keywords: Management, marsupialization, obstruction, ranula
|How to cite this article:|
Abdullahi M, Taiwo AO, Iseh KR, Amutta SB. Ranula: A retrospective clinicosurgical analysis of 29 cases from a tertiary health institution, Northwest, Nigeria. J Clin Sci 2021;18:109-12
|How to cite this URL:|
Abdullahi M, Taiwo AO, Iseh KR, Amutta SB. Ranula: A retrospective clinicosurgical analysis of 29 cases from a tertiary health institution, Northwest, Nigeria. J Clin Sci [serial online] 2021 [cited 2021 Jun 15];18:109-12. Available from: https://www.jcsjournal.org/text.asp?2021/18/2/109/314450
| Introduction|| |
Most ranulas are translucent, extravasation mucoceles that arise from the sublingual gland and may be quite extensive. The mucus extravasation pseudocyst may be confined to the floor of the mouth (simple ranula) or extend into the cervical region (plunging ranula).,,
Ranula can be acquired or congenital; most are attributed to trauma. A few are due to obstructive causes, while the causes in some are unknown.,,,
Most patients with ranula present with gradually enlarging swelling of the mouth floor which may involve the submandibular region., When significantly large, ranula may cross the midline to cause deviation and/or protrusion of the tongue. Ranula is easily diagnosed clinically from its location and appearance. However, ultrasonography, computed tomography, magnetic resonance imaging, and fine-needle aspiration cytology have also been used to rule out other differential diagnoses, in particular for patients with plunging ranulas.
Ranula is uncommon, and few surgeons encounter more than one lesion in each year; especially for plunging ranulas., Zhao et al., reported 580 patients with ranula over the period of 40 years, and they classified the ranula into oral, plunging, and mixed types. The oral type was the most common, and the age range of all kinds was between the ages of 3 months to 80 years.
In Nigeria, case reports on both congenital and plunging ranula have been documented in the literature., There is a dearth of information on the clinical profile of patients with ranula in Northwestern Nigeria.
The aim of this paper is to describe the clinical presentation, treatment, and outcome of patients with ranula, as seen in the Usmanu Danfodiyo University Teaching Hospital, Sokoto, Northwest, Nigeria.
| Methods|| |
A retrospective study of clinical records of patients with histological diagnoses of ranula managed at the Departments of Otorhinolaryngology, Dental and Maxillofacial Surgery of a Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria. Marsupialization was performed by excising the superior wall and suturing of the inner wall of the lesion to the mucosa of the floor of the mouth. The plunging ranulas were excised by careful blunt dissection through submandibular approach. Management of ranula was also carried out through sublingual gland excision with the evacuation of the cyst intraoperatively with no intension to cyst dissection. The data were retrieved between the periods of January 2000 to December 2019 were reviewed for age, sex, clinical features, treatment, and outcome. The inclusion criteria were patients with the histological diagnoses of a ranula. The exclusion criteria were patients with other cystic swellings such as a malignant cyst, cystic hygroma, and dermoid cyst. The data was analyzed using Predictive Analysis Software (PASW) version 18.0. (SPSS Inc. Released 2009. PASW statistic for windows, version 18.0: Chicago: SPSS Inc.)
Ethical clearance was obtained from the Tertiary Hospital's Research and Ethical committee.
| Results|| |
A total of 29 patients were seen during the study period. Twelve (41.4%) males and 17 (58.6%) females with a male-to-female ratio of 1:1.4. Age ranged from 3 days to 48 years (median 3 years). Most of the patients 19 (65.5%) were below the age of 10 years, as shown in [Figure 1]. Twenty-one (87.5%) patients had simple oral ranula [Figure 2], of which 8 (38.1%) of these cases were congenital ranulas. Plunging ranulas were seen in 8 (27.6.5%) patients and two (25%) of these patients were HIV infected. Eight (38.1%) patients with simple ranula presented with tongue protrusion and dysphagia, which were the main presenting complaint in children. Other presenting complaints were swelling from the floor of the mouth 13 (61.9%) and neck swellings 3 (12.5%).
|Figure 2: (a) Preoperative right simple ranula. (b) Intra-oral resection of the SLG and also showing submandibular duct (SM duct). SLG = Sublingual gland, SM=Submandibular|
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Simple marsupialization was done for 10 (34.5%) patients with simple oral ranula; one of these patients had tracheostomy because of difficult intubation. Sublingual salivary glands excisions were done for 16 (55.2%) patients, as shown in [Table 1]. One of the patients with plunging ranula refused surgery and opted for conservative treatment, however, the lesion ruptured without surgical intervention and the rest of the patients with a similar lesion had excision of the ranula through the submandibular approach shown in the outcome in [Table 1].
|Table 1: Treatment options, complication and follow up of patients with ranula|
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Injury to the Wharton's duct was seen in two (12.5%) patients who had sublingual gland excision [Table 1].
No recurrence was noted in 3 (30%) patients who had simple marsupialization before they were lost to follow up after <7 months of surgical intervention. Similarly, no recurrence was seen in 8 (50%) patients who had a sublingual gland excision (average of 3 months of follow-up). One of the two patients with plunging ranula who had excision of the ranula had a recurrence 2 years postsurgery. Twelve (41.4%) patients never come back for follow-up after they were discharged from the hospital.
| Discussion|| |
Ranula is a mucocele that includes the mucus extravasation phenomenon and mucus retention cyst. Most ranulas are found on the floor of the mouth and usually result from the sublingual gland. It is an uncommon condition with a prevalence of 0.2/1000 in most studies,, and this could explain why few cases were seen during the review period. In the present study, most of the cases of ranula involved the floor of the mouth. Zhao et al.; noted similar findings: they reported only 480 cases of a ranula in 40 years. Chidzonga and Mahomva in 2007, reported 83 cases of ranula in 22 years.
HIV and AIDS-associated ranula have been reported among Africans, where extensive fibrosis was found in mucus salivary glands.,,,,, Chidzonga and Rusakaniko suggested that blockage of the salivary ducts with consequent rupture of the acini and extravasation of the mucus may lead to ranula formation, this may explain the ranula formation in the two of our HIV-infected patients with plunging ranula. However, prospective studies with a large sample size are needed to verify this association in our environment.
The main treatment for ranula is surgical excision. A simple surgical incision and drainage may be complicated by 100% chances of recurrence and for simple marsupialization, may lead to 6%–89% chance of recurrence. A complete cure of ranula is achieved with surgical excision of the ranula, where 0% to 1.55% chance of recurrence was reported. However, Zhi et al., suggested conservative management for simple ranula; he reported that four of their patients had complete resolution with aspiration/marsupialization. A better outcome was reported by marsupialization with gauze packing. In this study, we chose to do simple marsupialization without gauze packing for 10 (41.6%) of our pediatric patients whose parents were financially handicapped for anesthesia. The children were malnourished, thus, the need for a conservative approach to minimize morbidity/comorbidities associated with sublingual gland excision. Moreover, a study has shown that complete resolution with conservative management is possible, and the resection ipsilateral sublingual gland was recommended if ranula recurred.
Studies have shown the potential impact on the regression of ranula with active antiretroviral treatment;, however, we cannot verify this effect in one of our patients who opted for conservative treatment with antiretroviral therapy because she was lost to follow-up. Prospective studies are needed to verify this claim in our environment.
| Conclusion|| |
Ranula is not a common condition and may present with obstructive symptoms when neglected. Definitive management is surgical excision. However, simple marsupialization is a treatment option that needs adequate follow-up to detect recurrence. Improvement in the management of ranula in our environment can be attained by creating public awareness for early presentation and appropriate follow-up.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]