Journal of ENT Care and Otolaryngology Research

Case Presentation Volume: 1, Issue: 1 Scientific Knowledge

Plunging . An Entity to Be Taken into Account in Cervical Masses - A Case Report Javier Gómez-Hervás*, Manuel Moreno Romera, Dionisio Pérez Mestre and Esteban Merino Gálvez Department of Ear, Nose and Throat, The Hospital Rafael Méndez, Spain

1. Abstract extending underneath it and dissecting the submandibular Background: The plunging ranula is a special type of and parapharyngeal spaces, presenting as a cervical mass. soil cannula of the mouth dependent on the sublingual Sometimes, there is no apparent connection with the gland that extends to the deep tissues of the , mouth, hence the name plunging or diving ranula [2,3]. A manifesting itself as a cervical mass. genetic origin has been suggested [4]. since this type of Methods and Results: We present the case of a patient ranula is more common amongst the Maoris and who presented with symptoms and signs of right Polynesians of the Pacific islands [5,6]. They have also submandibular cervical abscess of rapid progression been linked to previous floor of the mouth traumas. after extraction of a homolateral molar and which was Plunging are an uncommon entity and their operated with a transcervical approach draining only symptoms include the presence of a painless, unilateral salivary content. After drainage the patient remains submandibular mass. They are more common in patients asymptomatic after three years. under 30 years of age [5,7,8] with a certain predominance Conclusion: The purpose of this work is to indicate the in females [7,9,10]. Various methods have been proposed importance of this entity in the differential diagnosis of for their diagnosis, including computed tomography (CT) lesions of the neck, since its early detection can diminish with contrast material, nuclear magnetic resonance the Morbi motor of the patient. The plunging ranula is an (NMR), ultrasound and ultrasound-guided puncture to entity that must be taken into account in the differential confirm the presence of amylase in the mucoid fluid diagnosis of cervical masses since in its treatment obtained [11]. Differential diagnoses include cervical should include the exeresis of the sublingual gland to abscess, branchial cleft , , cystic prevent recurrence. hygroma, lymphangioma, lipoma and dermoid and 2. Keywords: Plunging ranula; Sublingual; Abscess; epidermoid [3,11]. Treatment for plunging ranulas Cervical is controversial, since numerous procedures have been 3. Introduction described, ranging from a simple aspiration to the partial or total excision of the ranula and sublingual gland, The term “ranula of the floor of the mouth” refers to a *Corresponding author: Javier Gómez Hervás, Department of Ear, Nose collection of fluid in the interstitium of the soft tissues and Throat, The Hospital Rafael Méndez, C./ Gloria Más 2, bloque 7, piso surrounding the sublingual gland [1]. They are 2 A, 18014, Lorca, Spain, Tel: +34 954 16 17 76; E- mail: [email protected] projecting towards the oral cavity in the form of a cyst. Received Date: July 03, 2019; Accepted Date: July 10, 2019; On occasions, they go beyond the mylohyoid muscle, Published Date: July 12, 2019 J ENT Care Otolaryngol Res 1 Volume 1 (1): 2019 marsupialization, dissection, cryotherapy, sclerotherapy performed under local anaesthetic in the emergency and laser ablation [12,10]. operating theatre, along with a left submaxillary Misdiagnosis as an abscess might point towards cervicotomy opening up the cavity that dissected the left treatment with simple drainage or marsupialization [10]. parapharyngeal space and continued to the floor of the The purpose of this work is to show the importance of mouth. Only a watery, translucent fluid was drained, this entity in the differential diagnosis of neck lesions, with no purulent content. since the early detection thereof may reduce patient morbidity and mortality. 4. Case Presentation A 28-year-old woman was seen for odynophagia and , referred to the left hemi pharynx and lasting three days, along with trismus, a fever of 38ºC and symptoms of dyspnoea. One week prior, she had undergone the extraction of a molar in the left lower arcade. A physical examination revealed a hyperaemic Figure 2: Dissection of the left submaxillary space. pharynx, a swollen left hemipharnyx displacing the Given that the postoperative period elapsed with no uvula to the right, and left-sided submandibular cervical further incidents, we proceeded to close the swelling with crackling indicative of subcutaneous tracheostomy and the patient was discharged after a emphysema. Her blood work showed a CRP level of favorable evolution. No relapse has been detected on 97.9, 17,800 leucocytes and 16,400 neutrophils. A control CT scans. collection of fluid compatible with an abscess was 5. Discussion observed on the cervical CT scan with contrast material Ranulas of the floor of the mouth arise as a result of saliva in the left side of the floor of the mouth, affecting the escaping from the sublingual glands [13]. Plunging floor of the mouth muscles and left submaxillary gland. ranula is a variant of this pathology, consisting of a Air bubbles were also seen in the left parapharyngeal pseudocyst formed by the extravasation of saliva from space fat, the masticator and masseter spaces and in the the sublingual gland, herniating towards the latero-cervical subcutaneous cell tissue. submandibular space, either via the posterior margin of the mylohyoid muscle or through an area of weakness thereof [14]. Once the ranula reaches the submandibular and cervical spaces, it may project onto the pharyngeal lumen, causing dysphagia and even respiratory failure due to compression [15] as with our patient, or protruding under the skin of the neck in the submandibular area. As regards the aetiology of the condition, a genetic origin has been proposed [5]. It has also been linked to a history Figure 1: On the left is a sagittal slice showing a hypodense lesion of trauma to the duct of Rivinus associated with the local occupying the left submaxillary space. The right shows the tail sign; extirpation of ranulas of the floor of the mouth [13]. One the communication of the submaxillary and sublingual space by the week prior, our patient underwent a molar extraction hypodense lesion, with its characteristic thinned anterior border, resembling a tail. which could trigger local inflammation. However, we do After the CT results and in light of a suspected not consider it to be related to the onset of the plunging parapharyngeal abscess, a safe tracheostomy was ranula. J ENT Care Otolaryngol Res 2 Volume 1 (1): 2019 Difficulties in diagnosis largely stem from the few case References studies on the topic. In fact, the entity is not referenced 1. Macdonald AJ, Salzman KL, Harnsberger HR. in reviews on cervical masses produced by Giant ranula of the neck: differentiation from cystic otorhinolaryngology journals, which do include cervical hygroma. AJNR Am J Neuroradiol. 2003; 24: 757-761. abscesses, branchial cleft cysts, thyroglossal cysts and 2. Kurabayashi T, Ida M, Yasumoto M, adenopathies [16], on the other hand. Thus, the ENT Ohbayashi N, Yoshino N, Tetsumura A, et al. MRI of specialist does not usually consider this pathology in the ranulas. Neuroradiology. 2000; 42: 917-922. differential diagnosis. For a certain diagnosis, various 3. Coit WE, Harnsberger HR, Osborn AG, methods have been proposed. Ultrasound-guided Smoker WR, Stevens MH, Lufkin RB. Ranulas and their puncture aspiration and subsequent specimen analysis to mimics: CT evaluation. Radiology. 1987; 163: 211-216. check for the presence of amylase [11] confirms the 4. George MM, Mirza O, Solanki K, Goswamy ranula, but may result in a high number of false J, Rothera MP. Serious neonatal airway obstruction with negatives [16]. CT or NMR with contrast material may massive congenital sublingual ranula and contralateral reveal a characteristic sign known as the tail sign, occurrence. Ann Med Surg (Lond). 2015; 4: 136-139. consisting of a communication between the 5. Morton RP, Ahmad Z, Jain P. Plunging submaxillary and sublingual space that presents as an ranula: congenital or acquired? Otolaryngol Head Neck anterior prolongation of the pseudo cystic contents Surg. 2010; 142: 104-107. which gets progressively thinner [3,16,17]. In our case, 6. Davison MJ, Morton RP, McIvor NP. this sign did appear. However, neither we nor the Plunging ranula: clinical observations. Head Neck. 1998; radiologist realized, so it was treated first as a pharyngeal 20: 63-68. abscess. The therapeutic approach is not completely 7. Zhao YF, Jia Y, Chen XM, Zhang WF. standardized. Puncture and aspiration alone are not Clinical review of 580 ranulas. Oral Surg Oral Med Oral advised due to the high number of relapses [10], Pathol Oral Radiol Endod. 2004; 98: 281-287. although puncture followed by ethanol injection is 8. Batsakis JG, McClatchey KD. Cervical described with good results [18]. ranulas. Ann Otol Rhinol Laryngol. 1988; 97: 561-562. Drainage of the ranula alongside sublingual gland 9. Chidzonga MM, Rusakaniko S. Ranula: excision via the transoral or cervical approach provides another HIV/ AIDS associated oral lesion in Zimbabwe? a much better outcome, both as an isolated procedure or Oral Dis. 2004; 10: 229-232. in combination [13,14,18]. 10. Kokong D, Iduh A, Chukwu I, Mugu J, Nuhu In our case, we performed a drainage and excised the S, Augustine S. Ranula: Current Concept of pseudocyst using the transcervical approach; the long- Pathophysiologic Basis and Surgical Management term outcome was satisfactory given the absence of Options. World J Surg. 2017; 41: 1476-1481. relapses. 11. Jain R, Morton RP, Ahmad Z. Diagnostic 6. Conclusion difficulties of plunging ranula: case series. J Laryngol Plunging ranula is an entity that should be taken into Otol. 2012; 126: 506-510. account by ENT specialists in the differential 12. Charnoff SK, Carter BL. Plunging ranula: CT diagnosis of cervical lesions, particularly in young diagnosis. Radiology. 1986; 158: 467- 468. women with a painless cervical mass. Only through 13. Harrison, JD. Modern management and early diagnosis will the correct therapeutic management pathophysiology of ranula: literature review. Head Neck. of these types of lesions be performed, avoiding the need 2010; 32: 1310-1320. to perform insufficient or excessive therapeutic 14. Samant S, Morton R, Ahmad Z. for manoeuvres. plunging ranula: the lesson not yet learned? Eur Arch J ENT Care Otolaryngol Res 3 Volume 1 (1): 2019 Otorhinolaryngol. 2011; 268: 1513-1518. 17. Lee JY, Lee HY, Kim HJ, Jeong HS, Kim YK, 15. Effat KG. Acute presentation of a plunging Cha J, et al. Plunging Ranulas Revisited: A CT Study ranula causing respiratory distress: case report. J with Emphasis on a Defect of the Mylohyoid Muscle as Laryngol Otol. 2012; 126: 861-863. the Primary Route of Lesion Propagation. Korean J 16. Lomas J, Chandran D, Whitfield BCS. Radiol. 2016; 17: 264-270. Surgical management of plunging ranulas: a 10-year 18. Nguyen MLT, Orloff LA. Successful ablation case series in South East Queensland. ANZ J Surg. of plunging ranula by ultrasound- guided percutaneous 2018; 88: 1043- 1046. ethanol injection. Laryngoscope. 2017: 127: 2239-2241.

Citation: Javier Gómez-Hervás, Manuel Moreno Romera, Dionisio Pérez Mestre, Esteban Merino Gálvez. Plunging Ranula. An Entity to Be Taken into Account in Cervical Masses - A Case Report. J ENT Care Otolaryngol Res. 2019; 1: 1001.

Copy Right: © 2019 Javier Gómez-Hervás. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. J ENT Care Otolaryngol Res 4 Volume 1 (1): 2019