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Management of Ranula

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Management of Ranula MANAGEMENT OF RANULA rd 3 Literature review Submitted by: Puji Sulastri 09/303021/PKU/11459 OTORHINOLARINGOLOGY HEAD AND NECK SURGERY DEPARTEMENT FACULTY OF MEDICINE GADJAH MADA UNIVERSITY YOGYAKARTA 2014 APPROVAL SHEET nd 3 Literature review MANAGEMENT OF RANULA Submitted by: Puji Sulastri 09/308818/PKU/11975 Approved by: Supervisor: dr. Camelia Herdini, M.Kes, Sp.THT-KL Head of Study Programme Otorhinolaryngology Head and Neck Surgery Departement Faculty of Medicine Gadjah Mada University dr. Sagung Rai Indrasari, M.Kes, Sp. THT-KL (K) TABLE OF CONTENT Table of content ……………………………………………………………………. Chapter I. Introduction ……………………………………………………………... 1 A. Background…………………………………………………………………. 1 B. Problem statement…………………………………………………………... 3 C. Purpose of literature review………………………………………………… 3 Chapter II. Literature Review 4 A. Anatomy Submandibular Glands and Sublingual glands…………………... 4 1. Submandibular Glands………………………………………………….. 4 2. Sublingual glands……………………………………………………….. 6 B. Physiology of Salivary Glands……………………………………………… 7 C. Ranula………………………………………………………………………. 8 1. Definition……………………………………………………………….. 8 2. Etiology………………………………………………………………… 9 3. Epidemiology…………………………………………………………… 9 4. Pathogenesis…………………………………………………………….. 10 5. Classification……………………………………………………………. 12 6. Diagnosis………………………………………………………………... 13 7. Additional examination…………………………………………………. 15 8. Differential Diagnosis…………………………………………………... 17 9. Treatment……………………………………………………………….. 18 a. Marsupialization……………………………………………………. 18 b. Excision of the sublingual gland…………………………………..... 20 c. Excision of plunging ranula………………………………………… 22 d. Intralesional Injection of OK-432…………………………………... 24 e. Hydrodissection…………………………………………………….. 28 Chapter III. Summary………………………………………………………………. 30 Alghoritm Management of Ranula…………………………………………………. 32 References…………………………………………………………………………... 33 1 CHAPTER I INTRODUCTION A. Background Ranula is reported by Hippocrates and celcius. Theoretically, the ranula formation is excretory duct rupture followed by extravasation and accumulation of saliva into the surrounding tissue. The accumulation of mucous into the surrounding connective tissue forms a pseudocyst that lacks an epithelial lining . The analysis of the saliva reveals a high protein and amylase concentration consistent with secretions from the mucinous acini in the sublingual gland. The high protein content may produce a very intense inflammatory reaction and mediate pseudocyst formation (Jaishankar et al, 2010). The classic ranula presents as a blue-domed, translucent swelling in the floor of the mouth. The term ranula is derived from the Latin word rana, meaning frog, and describes a blue translucent swelling in the floor of the mouth reminiscent of the underbelly of a frog (Al-Sadhan R,2009). Ranula may be seen at birth or in later life. It is commonly seen in young adult. Ranula commonly occurs unilaterally, and bilateral ranulas are extremely rare (Yaman et al, 2006). Ranula develops from extravasation of mucus after trauma to the sublingual gland or obstruction of the ducts. Ranula can present at any age. It has been reported from 2 to 61 years of age with a slight female preponderance. Regarding the Patel et al. study a total of 26 ranulas were identified at their institution over an 18-year 2 period. There were 54% male and 46% female patients with an average age of 25.6 and a median age of 26. Of the 26 ranulas identified, 16 were oral (62%) and 10 were plunging (38%) (Sheikhi et al, 2011). The prevalence of ranula is about 0.2 cases per 1000 persons and accounts for 6% of all oral sialocysts. Only 1% to 10% of the ranulas are true retention cysts. Ranula usually occurs in children and young adults. The peak frequency of ranula occurs in the second decade of life (Zhao et al, 2004). A Study of 83 cases of ranula in Zimbabwe revealed high prevalence of ranula in HIV positive subjects, suggesting HIV salivary gland disease could be an etiologic factor is possibly a result of obstruction for the following reasons: there is an increase of inflammation and fibrosis in minor salivary glands of patients with untreated HIV(this would also involve the biologically similar sublingual glands), inflammation and fibrosis cause obstruction of salivary glands, and obstruction of the sublingual glands leads to extravasation and possibly the development of ranulas in patients with untreated HIV infection (Chidzonga et al, 2007). Sublingual glands are the smallest of the paired major salivary glands, weighing about 2 g, and shaped like a flattened almond measuring about 2.5 cm anteroposteriorly, each gland has a row of about 12–20 short ducts that open independently along the summit of the sublingual fold in the floor of the mouth, obstruction of one of these ducts results in formation of a mucous retention cyst in the sublingual space, termed simple ranula, further accumulation of secretions with time results in extension along sublingual space anteriorly and posteriorly, if posterior 3 extension extends or extravasates beyond the free edge of, or through the mylohyoid muscle (Sheikhi et al, 2011). A variety of surgical procedures have been quoted in the literature ranging from marsupialization, excision of the ranula, sclerotherapy, and excision of the sublingual gland. The recurrence rate varies according to the procedure performed (Sheikhi et al, 2011). B. Problem statement The ranula is a form of mucocele which specially occurs in the floor of the mouth. Several surgical techniques had been introduced to treat intraoral ranula. Marsupialization, excision of the sublingual gland or combined excision of both the ranula and the sublingual gland have been used with variable success rates. The optimal treatment option is still very controversial. Ranula diseases we encounter in everyday practice ENT specialist so we need a broad knowledge of management. Discussed in the literature about the management of ranula wide range of both surgical and non-surgical. because it was expected we could provide therapeutic ranula well. C. Purpose of literature review This literature review provides a knowledge about management of ranula. 4 CHAPTER II LITERATURE REVIEW A. Anatomy Submandibular Glands and Sublingual glands 1. Submandibular Glands The second largest major salivary gland is the submandibular (submaxillary) gland. It comprises both mucous and serous cells. The gland lies in the submandibular triangle, which is formed by the anterior and posterior bellies of the digastric muscle and the inferior margin of the mandible (Fig. 1). The gland lies medial and inferior to the mandibular ramus and wraps around the mylohyoid muscle in a C-shaped fashion to produce a superficial and deep lobe (Fig.2). Figure 1: The submandibular triangle. Note the relationship of the marginal mandibular nerve to the mandible and facial vessels. (Bailey, 2006) The superficial lobe of the submandibular gland lies in the lateral sublingual space. The deep lobe of the gland (actually first encountered during a routine submandibular gland excision) lies inferior to the mylohyoid muscle and constitutes the bulk of the gland. The superficial layer of deep cervical fascia splits to envelop the gland. Wharton duct exits from the medial surface of the gland and travels 5 between the mylohyoid and hyoglossus muscles onto the genioglossus muscle. It then opens intraorally lateral to the lingual frenulum at the floor of the mouth. The duct is approximately 5 cm in length. As the duct exits the gland, the hypoglossal nerve lies inferiorly and the lingual nerve superiorly (Bailey, 2006). Figure 2: The superficial and deep lobes of submandibular gland are separated by the mylohyoid muscle. The sublingual gland has multiple ducts that open along the plica of the floor of the mouth (Bailey, 2006) The submandibular gland is innervated by the sympathetic nervous system (SNS) and parasympathetic nervous system (PNS), which stimulate the gland to produce mucoid and watery saliva, respectively. The PNS supply is from the chorda tympani nerve, which is a branch of the facial nerve. The chorda carries preganglionic parasympathetic fibers to the submandibular ganglion by means of the lingual nerve. At the submandibular ganglion, the fibers synapse onto postganglionic parasympathetic fibers that stimulate the gland to produce saliva. The sympathetic fibers originate in the superior cervical ganglion and travel with the lingual artery to the gland (Bailey, 2006). The facial artery provides the major blood supply to the gland. The artery, which is a major branch of the external carotid artery, grooves the deep portion of the 6 submandibular gland as it courses superiorly and anteriorly. At the superior aspect of the gland, it passes laterally and curves around a notch in the mandible to supply the face. The anterior facial vein drains the gland. The marginal mandibular branch of the facial nerve lies superficial to the anterior facial vein. One maneuver to preserve the nerve during disection is ligation and elevation of the vein superiorly off the gland, thereby protecting it in the elevated fascia. Lymph nodes are present between the gland and the capsular fascia but not deep in glandular tissue. The nodes drain into the deep cervical and jugular chains (Bailey, 2006). 2. Sublingual glands The sublingual gland is the smallest of the major salivary glands and lies just below the floor of mouth mucosa. It contains primarily mucus-secreting acinar cells. The gland is bordered by the mandible and genioglossus muscle laterally and the
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