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| EDITORIAL |
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Year : 2014? |? Volume : 3? |? Issue : 2? |? Page : 77-78 |
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Ranula: A misunderstood disease
John D Harrison
Clinical and Diagnostic Sciences Group, King's College London Dental Institute at Guy's, King's College and St Thomas' Hospitals, London, England, United Kingdom
| Date of Web Publication |
6-Aug-2014 |
Correspondence Address:
John D Harrison
Head and Neck Pathology, Floor 4, Tower Wing, Guy's Hospital, London, SE1 9RT, England
United Kingdom
DOI: 10.4103/2278-9588.138212
How to cite this article:
Harrison JD. Ranula: A misunderstood disease. J Cranio Max Dis 2014;3:77-8 |
How to cite this URL:
Harrison JD. Ranula: A misunderstood disease. J Cranio Max Dis [serial online] 2014 [cited?2015 Feb 4];3:77-8. Available from:?https://craniomaxillary.com/text.asp?2014/3/2/77/138212 |
Ranulas were discovered to arise from the sublingual gland in the 19 th century, and they were discovered to be extravasation mucoceles that arose from a damaged sublingual duct in the middle of the 20 th century, although they can also arise by extravasation from an obstructed sublingual gland. [1],[2] Although this knowledge led to the successful treatment of ranulas by removal of the sublingual gland, there has been no shortage of misunderstanding about the nature of the ranula, which has led to inappropriate treatment, such as removal of the submandibular gland, or removal of the sac of the ranula, which is unnecessary because the extravasation mucocele is lined by inflamed granulation tissue, which will be resorbed once the supply of extravasated mucus stops. [1],[2],[3]
The anatomy of the sublingual gland is more complex than is generally realized. [1],[2] The sublingual gland lacks a capsule or fascial sheath and is in areolar tissue between the mucosa of the floor of the mouth and the mylohyoid muscle. A lesser sublingual gland is always present and consists of a mass of numerous small glands, which number from 15 to 30, are elongated vertically, and from every one of which a short duct of Rivinus passes to the plica sublingualis. A greater sublingual gland, which is situated between the lesser sublingual gland anterolaterally and Wharton's duct medially, is sometimes present and then usually unilaterally. Bartholin's duct passes from the greater sublingual gland either to join Wharton's duct or to run alongside it to open next to it at the caruncula sublingualis. A histological investigation of oral ranulas removed with the attached part of the sublingual gland demonstrated the source of the ranula to be a torn duct of Rivinus in every case. [4] This can also be the cause of a plunging ranula, when the extravasated mucus tracks around the posterior margin of the mylohyoid muscle or through a mylohyoid hiatus, which in a postmortem investigation was found to be present in 43% of cadavers. [5] Plunging ranulas could also arise from trauma to or obstructive constriction of sublingual gland herniated through a mylohyoid hiatus. [1],[2],[3],[5] The bilateral ranulas in the article by Date et al., could have arisen from damage to ducts of Rivinus during chewing.
Various conservative therapies have been attempted in order to avoid removal of the sublingual gland, and the more successful ones involving larger numbers of patients include marsupialization with packing, micromarsupialization by seton, [1],[2] and a series of 18 children with ranulas who were all reported to have been successfully treated with homeopathic medicines. [6] Marsupialization with packing is successful because the pack immediately obstructs extravasation from the sublingual gland and induces fibrotic sealing of the leak. Micromarsupialization of oral ranulas by seton in which sutures are inserted into the roof of the ranula is successful because the mucus in the ranula leaks away around the sutures and the sac decreases in size until the damaged duct regenerates. The reason for the success using homeopathic medicines in children is not clear. However, there is always an attempt by the body to limit an extravasation of mucus by inflammatory fibrosis of the leak, [1],[2] and possibly the homeopathic medicines improved the effectiveness of the inflammatory process. [6]
Another medical treatment of ranula in children with some reported success is highly active antiretroviral therapy (HAART) in HIV-positive children. [7] There appears to be an association of ranula with HIV-positive patients, which is possibly caused by obstruction of the sublingual gland by a lymphoid hyperplasia in HIV-positive patients, which may be reversed by HAART.
The key to understanding the ranula and its management is the realization that the sublingual gland is a spontaneous secretor that produces a continuous flow of mucus even in the absence of nervous stimulation and that it has a great resistance to obstruction. In a case of ranula, a balance is established between sublingual secretory activity and the attempts of the body to limit the extravasation by inflammatory fibrosis and by removal of mucus by macrophages. [8] Effective therapy changes the balance. This can be achieved essentially in two ways. One is to eliminate or reduce the supply of mucus by sublingual sialadenectomy or in two reports by injection of botulinum toxin. The other is to assist the reaction of the body by encouraging fibrosis to seal the leak or by allowing the extravasated mucus to drain to reduce the size of the ranula until the duct reforms as in micromarsupialization by seton. [1],[2]
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??References |
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| 1. |
Harrison JD. Modern management and pathophysiology of ranula: Literature review. Head Neck 2010;32:1310-20.??
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| 2. |
Harrison JD. Aetiology and treatment of ranula. J ENT Masterclass 2010;3:22-5.??
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| 3. |
Samant S, Morton RP, Ahmad Z. Surgery for plunging ranula: The lesson not yet learned? Eur Arch Otorhinolaryngol 2011;268:1513-8.??
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| 4. |
McGurk M, Eyeson J, Thomas B, Harrison JD. Conservative treatment of oral ranula by excision with minimal excision of the sublingual gland: Histological support for a traumatic etiology. J Oral Maxillofac Surg 2008;66:2050-7.??
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| 5. |
Harrison JD, Kim A, Al-Ali S, Morton RP. Postmortem investigation of mylohyoid hiatus and hernia: Aetiological factors of plunging ranula. Clin Anat 2013;26:693-9.??
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| 6. |
Garofalo S, Mussa A, Mostert M, Suteu L, Vinardi S, Gamba S, et al. Successful medical treatment for ranula in children. Oral Surg Oral Med Oral Pathol Oral Radiol 2014;117:e289-97.??
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| 7. |
Syebele K, Munzhelele TI. The potential impact of highly active antiretroviral therapy on the treatment and epidemiology of ranula in human immunodeficiency virus-positive patients. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;116:e32-6.??
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| 8. |
Harrison JD. Salivary mucoceles. Oral Surg Oral Med Oral Pathol 1975;39:268-78.??
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