A Large Plunging Ranula Causing Sleep Apnoea: a Case Report. Int J Health Sci Res

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Case Report

A Large Plunging Ranula Causing Sleep Apnoea: A Case Report

Haritosh K. Velankar1, Yogesh G. Dabholkar2, Naresh Dawat3, Saurabh Kansal4, Akanksha Saberwal5

1Professor and Head of Department, 2Professor, 3Ist Year PG. E.N.T. Resident, 4Post MS -Senior Resident, 53rd Year PG. E.N.T. Resident; Dept. of E.N.T., Dr. D.Y.Patil Hospital and Research Centre, Nerul, Navi Mumbai- 400706

Corresponding Author: Haritosh K. Velankar

Received: 15/03//2014 Revised: 13/04/2014 Accepted: 17/04/2014

ABSTRACT

Plunging ranulas, also known as deep diving, cervical or deep plunging ranula, usually appear in conjunction with oral ranula. Rarely, these ranulas may arise as independent of oral swelling. Large lesion with resultant elevation of the tongue not only interferes with swallowing (dysphagia) but also results in snoring and sleeps apneoa. A rare case of plunging ranula with minimal oral swelling is discussed along with a review of literature.

Keywords: Dysphagia, plunging, ranula, sleep apnoea, sublingual gland.

INTRODUCTION planes and muscles of the base of the tongue A ranula is a type of mucocele found to the submandibular space. The exact on the floor of the mouth, consisting of prevalence of plunging ranula is not known, collected mucin from an obstructed or however, these lesions are considered ruptured salivary gland duct, usually in uncommon. A cervical ranula presents as a relation to the sublingual gland. The latin swelling in the neck with or without a word 'rana' means frog (ranula=little frog). swelling in the mouth. The usual location is The etymology of the term is usually lateral to the midline, which may help to explained by a resemblance with the distinguish from a midline dermoid cyst. underbelly, or the bulging throat of a Ranulas may be asymptomatic although they croaking frog. Usually a ranula is confined can fluctuate rapidly in size, shrinking and to the floor of the mouth (termed a "simple swelling. A large ranula may sometimes ranula"). An unusual variant is the cervical interfere with swallowing, causing ranula (also called as plunging or diving dysphagia. The purpose of this paper is to ranual), where the swelling is in the neck present the clinical and radiographic rather than the floor of the mouth. A findings of an uncommon presentation of a plunging ranula is an extravasation of saliva large plunging ranula with sleep apnoea and from the sublingual gland due to trauma or dysphagia. obstruction of the gland. Fluid from the obstructed gland dissects between the fascial CASE REPORT

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A 50-year-old female reported with a deep component. MRI showing cystic lesion right-sided neck swelling. There was on the left side in the sublingual region intermittent change in the size of the extending into the submental region, swelling since it was first noticed twelve submandibular region, and the left months back. On examination, a nonwarm, parapharyngeal region up to the pharynx. nontender, diffuse, soft, fluctuant, swelling, Based upon the clinicoradiological about 10 × 8 cm in size, was present in the and MRI findings, a tentative diagnosis of submental region. The overlying skin was plunging ranula was made with a differential normal. Intraorally, swelling was evident in diagnosis of dermoid and epidermoid cyst, the sublingual areas bilaterally as a thyroglossal duct cyst, cystic hygroma, and translucent blue, dome-shaped. The lymphadenopathy. The excision of the lesion overlying mucosa was normal and was done via cervical approach under Wharton's duct openings were patent. general anaesthesia and the tissue was Orthopantomograph of the patient subjected to histopathological evaluation. failed to show any sialolithiasis. Histopathological picture of the excised Ultrasonography of the swelling showed an lesion showed mucin collection in the lumen anechoic, bilobed fluid collection in left lined by connective tissue with submandibular region with a superficial and inflammatory cells.

Fig 1. Intra Oral Swelling. Fig 2 Neck Swelling. Fig 3. Intra Operative.

DISCUSSION described in association with congenital Ranula develops from extravasation anomalies, trauma, and disease of the of mucus after trauma to the sublingual sublingual gland. [4] gland or obstruction of the ducts. [1,2] The most common etiology of Although a ranula can present at any age, ranulas is partial obstruction of a sublingual usually it occurs in children and young duct, leading to formation of an epithelial- adults, with the peak frequency in the lined retention cyst, which occurs in <10% second decade. [3] The cervical variant tends of all ranulas. Second, most common cause to occur a little later in the third decade. The is trauma, often iatrogenic, resulting in diagnosis of a plunging ranula is usually direct damage to the duct or deeper areas of determined by a combination of history, the body of the sublingual gland, leading to clinical presentation, and imaging studies. extravasation of mucus and formation of The etiology is unknown, but it has been pseudocyst.

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Mechanisms of formation of imaging (MRI), CT, and aspiration cytology plunging ranula are varied. Approximately can be helpful for diagnosis. Aspiration 45% of plunging ranulas occur cytology will show mucin with muciphages iatrogenically after surgery to remove oral and biochemical analysis will show increase ranulas. Cases of plunging ranula arising in amylase and protein content. This is after surgical procedures for sialolith diagnostic of the salivary origin. [9] removal, duct transposition and implant Computed tomography and placement have alsobeen reported. [5-7] specifically the presence of ―tail sign‖ is Sometimes, a dehiscence or hiatus in the pathognomonic for the plunging ranula. [10] mylohyoid muscle may occur. This defect is This tail is due to extension behind the observed along the lateral aspect of the mylohyoid muscle and confirms the ranula anterior two-thirds of the muscle. Through to arise from the sublingual gland and is this defect, the mucin from the sublingual especially useful in differential diagnosis of gland may penetrate to the submandibular cervical ranula. space. Occassionally, the sublingual gland Surgery is the main stay for the may project through the mylohyoid, or an management of ranulas. These include ectopic sublingual gland may exist on the incision and drainage, excision of ranula, cervical side of mylohyoid. This explains marsupialization, and marsupialization with most plunging ranulas that exist without an packing or complete excision of the oral component. Lastly, a ranula may arise sublingual gland. Simple marsupialization from a duct of the sublingual gland which has fallen into disfavor primarily because of has joined the submandibular gland or its the failure rate, which has been anywhere duct. In such cases, the ranula may form in from 61% to 89%. Marsupialization with continuity with the submandibular gland and packing of the cyst cavity may reduce the access the neck from behind the mylohyoid recurrence. muscle. [8] Extraoral excision has also been The cervical ranula appears as an done due to the fear of injury to Wharton’s asymptomatic, continuously enlarging mass duct and lingual nerve. Excision of the that may fluctuate in size. Most reported ranula with the associated sublingual ranulas are 4–10 cm in size. The overlying salivary gland is the most accepted method skin is usually intact. The mass is fluctuant, with low recurrence rate. [11] freely movable, and nontender. Rarely, Other treatment modalities have also large-sized ranulas may cause dysphagia or been utilized. Sclerotherapy with OK-432 is airway obstruction. In our case, the ranula a good substitute for surgery. [12] Recurrence had developed into a large lesion many was noted in 14.3% and the patient had an centimetres in diameter, with resultant average of 1.7 injections. Fukase et al. used elevation of the tongue. As such the lesions a higher concentration in partially regressed not only interfered with swallowing cases and had 100% cure rate. [13] (dysphagia) but also resulted in snoring and sleep apneoa. These complaints disappeared CONCLUSION with excision of the ranula. A ranula is often asymptomatic, but Ranula is a clinical diagnosis, and a plunging ranula can sometimes grow large imaging studies are done mainly to know the enough to cause dysphagia and sleep extension of swelling prior to surgery or disturbed breathing. The definitive treatment when the diagnosis is unclear. Sialogram, for plunging ranula is transcervical excision ultrasonography, Magnetic resonance International Journal of Health Sciences & Research (www.ijhsr.org) 303 Vol.4; Issue: 5; May 2014 of the ranula along with the ipsilateral complication of dental implant sublingual gland. surgery: a case report. Journal of Oral and Maxillofacial Surgery. REFERENCES 2006;64(8):1204–1208. 1. Baurmash HD. Mucoceles and 8. de Visscher JGAM, van der Wal ranulas. Journal of Oral and KGH, de Vogel PL. The plunging Maxillofacial Surgery. ranula. Pathogenesis, diagnosis and 2003;61(3):369–378. management. Journal of Cranio- 2. Neville BD, Damm DD, Allen CM, Maxillo-Facial Surgery. 1989;17(4): Bouquot JE. Oral and Maxillofacial 182–185. Pathology. 2nd edition. Philadelphia, 9. Arunachalam P, Priyadharshini N. Pa, USA: Saunders; 2002. Recurrent plunging ranula. J Indian 3. Zhao Y-F, Jia Y, Chen X-M, Zhang Assoc Pediatr Surg. 2010;15:36–8. W-F. Clinical review of 580 ranulas. 10. 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How to cite this article: Velankar HK, Dabholkar YG, Dawat N et. al. A large plunging ranula causing sleep apnoea: a case report. Int J Health Sci Res. 2014;4(5):301-304.

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International Journal of Health Sciences & Research (www.ijhsr.org) 304 Vol.4; Issue: 5; May 2014