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see also: Plunging Ranula now antiquated treatment (see comments about contemporary treatment) and Recurrent neck swelling after ranula resection

Plunging ranula management in 20 yo with 7 month history of painless neck swelling without identified inciting event

Modified Operative Note

After informed consent was reviewed, the patient was brought back to the main operating room, placed in a supine position, and orotracheally intubated. The bed was turned 180 degrees from anesthesia. A throat pack was placed followed by intraoral adminstration of dilute betadine solution (then suctioned free) followed by a light facial prep with dilute betadine. The patient was draped for transoral surgery with exposure of the neck for potential cervical approach. The sterilely draped microscope was brought into place. Use of the 'Ringgold plastic mouth retractor' permitted exposure of the floor of mouth with posterior retraction on the tonge with a kittner.

The right submandibular duct was identified and a 0.015 inch guidewire was passed without difficulty over which the duct was then dilated with a Marchal dilator. The diagnostic sialoendoscope was passed into the right submandibular duct with no gross abnormalities. The sialoendoscope was then removed and the Marchal dilator again placed and left in place to allow for identification and preservation of the duct during the sublingual gland resection. Two 5-0 vicryl sutures were placed adjacent the duct orifice (superior and inferior) to assist in its further identification as needed, taking care to avoid injury to theduct with the suture placement.

 An incision was made using a scalpel along the right floor of mouth. Dissection was carried down to the sublingual gland using a combination of blunt and sharp dissection with scissors. The lingual nerve was identified and preserved. Care was taken to avoid injury to the submandibular duct. Thick yellow mucoid material was encountered within the pseudocyst at the mid lower border of the sublingual gland. The sublingual gland was resected in its entirety and partial resection of the pseudocyst included its upper portion where it was attached to the sublingual gland. The submandibular gland was exposed but not violated. The sublingual gland was sent for permanent pathology. Hemostasis was achieved during the procedure by hemoclips and bipolar cautery. Tannic acid was applied to the raw surface dissection to assist in final hemostasis. The Marchal dilator was removed. The throat pack was removed. The patient was turned back to anesthesia, extubated, and taken to the PACU in stable condition

References

Song T, Chiu W, de Paiva Leite S, Ahmad Z, Mahadevan M, Harrison JD, Jain P, Morton RP. Amylase as a Diagnostic Tool for Plunging Ranula: Clinical Series and Description of the Technique. Laryngoscope. 2023 Mar;133(3):535-538. doi: 10.1002/lary.30243. Epub 2022 Jun 7. PMID: 35670504.

Morton RP. Surgical Management of Ranula Revisited. World J Surg. 2018 Sep;42(9):3062-3063. doi: 10.1007/s00268-018-4666-y. PMID: 29750326.

Kokong D, Iduh A, Chukwu I, Mugu J, Nuhu S, Augustine S (2017) Ranula: current concept of pathophysiologic basis and surgical management options. World J Surg 41:1476–1481. https://doi.org/10.1007/s00268-017-3901-2

Harrison JD (2010) Modern management and pathophysiology of ranula: literature review. Head Neck 32:1310–1320

Kiesler K, Gugatschka M, Friedrich G. Incidence and clinical relevance of herniation of the mylohyoid muscle with penetration of the sublingual gland. Eur Arch Otorhinolaryngol. 2007 Sep;264(9):1071-4. doi: 10.1007/s00405-007-0321-1. Epub 2007 May 4. PMID: 17479273.

Ogle OE. Excision of Sublingual Gland. Oral Maxillofac Surg Clin North Am. 2021 May;33(2):161-168. doi: 10.1016/j.coms.2020.12.001. Epub 2021 Jan 29. PMID: 33526317.