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BackTable / ENT / Article
Surgical Management of the Plunging Ranula
Julia Casazza • Aug 16, 2023 • 82 hits
The smallest of the three major salivary glands, the sublingual gland, produces 1% of the body’s saliva but accounts for 90% of ranulae. When a ranula “plunges” through weaknesses in the floor of the mouth to enter the neck, it can present as a painful neck swelling. Treatment of the plunging ranula is sublingual gland excision, an effective, well-tolerated surgery. Dr. Rohan Walvekar, professor of otolaryngology at LSU health and expert in benign salivary disease, recommends a transoral approach to this operation.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• A plunging ranula is a salivary pseudocyst originating from the sublingual gland that has entered the neck. Aspiration of the pseudocyst does not resolve the condition as fluid tends to re-accumulate.
• Active sialadenitis is a contraindication to sublingual gland excision.
• Patients may be frustrated that surgery is needed to treat their condition. Dr. Walvekar recommends taking time to explain the condition’s pathophysiology so that patients understand why surgery is necessary.
• Salivary stents and sialendoscopy can be used intra-operatively to help identify and preserve the submandibular duct.
• Risks of sublingual gland removal include lingual nerve injury, submandibular duct injury, and infection.
Table of Contents
(1) “Why Can’t You Just Drain It?:” Counseling Patients on Plunging Ranula Surgery
(2) Operative Approach to the Plunging Ranula
(3) Complications of Sublingual Gland Removal
“Why Can’t You Just Drain It?:” Counseling Patients on Plunging Ranula Surgery
Upon presenting to the office, many patients with plunging ranulae inquire whether the pseudocyst can be aspirated; it is, after all, a collection of fluid. However, since the sublingual gland – the source of the ranula – continues to make saliva, a drained ranula will eventually re-accumulate following drainage. Dr. Walvekar recommends taking time to explain salivary anatomy and pathophysiology to patients. He finds it helpful to analogize the ranula to a puddle of liquid coming from a faucet (the sublingual gland); in order to stop the flow of liquid (and cure the condition), sublingual gland excision is required. The only notable contraindication to this operation is sialadenitis, which can be treated with oral amoxicillin-clavulanate or clindamycin prior to the operation.
[Ashley Agan MD]
Then moving on to when you start talking about treatment for these patients, is anyone like, "What if you just stick a needle in it and just drain it? What about that? Maybe I don't want to have surgery."? Does that work?
[Rohan Walvekar MD]
Yes. That's a great question. If it's just purely a floor of mouth ranula, certainly I don't push for sublingual gland excision at the first go. You can try the aspiration and see if it works or you can just sometimes apply a little bit of local and decap the cyst and if it just heals in a way that that cyst stays open, and sticks to the floor of the mouth, you may not have to have surgery. It's a really good question. If you have a true plunging ranula, can you just aspirate all of it and see if it goes away?"
In my experience, it doesn't.
I think at that point, this may be a terrible dad joke, but it's the cat's out of the bag Bill, the saliva is out of the floor of the mouth. It's done. I don't think there's any going back from having to take out that sublingual gland, but it's certainly a valid question. What I would talk about in the treatment is the important thing in my mind is removing that sublingual gland. Once that's done, conceptually, and if you have to go with the theory, then you will have basically no possibility of this fluid recollecting.
When you have fluid or component of this plunging ranula that's disconnected with the sublingual gland, I often recommend that and tell patients that, "Listen, all of this is not going to go away with the surgery. We're going to focus on removing the sublingual gland, but then I may have to come from the outside and just aspirate the fluid because we know that it will hopefully not recollect in the future."
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Operative Approach to the Plunging Ranula
Transoral resection of a plunging ranula relies upon detailed knowledge of the mouth anatomy and meticulous surgical technique. For Dr. Walvekar, surgery begins with an attempt to cannulate the submandibular duct; in cases of a large ranula, this may be delayed until after excision of the ranula. The operation requires careful dissection of minor salivary glands and fibro-fatty tissue to identify the myelohyoid muscle, submandibular duct, and lingual nerve. Once these structures are located, he proceeds with excision of the sublingual gland. Gland removal usually produces rapid ranula decompression. In more persistent cases, transoral dissection can access the ranula for decompression. He ends with sialendoscopy to confirm integrity of the nearby submandibular gland and its duct.
[Ashley Agan MD]
The stent that you're talking about is your stent that you developed, yes?
[Rohan Walvekar MD]
Yes. I mean, I use my stent. There are other stents available. Schaitkin has a stent through Hood Labs. My stent is also developed and manufactured by Hood Labs, which is a very nice company based in Pembroke Massachusetts. It's a small company, but they're very responsive. You can also use infant feeding tubes, but again, you can even leave a Cook catheter in place if you'd like. The reason why I put the stent in is because it has a flange, it has a way to anchor it to the floor of the mouth, then I don't have to keep worrying about the stent or whatever I put in the duct falling out every few minutes.
[Ashley Agan MD]
I like your stent because on the Hood website, it has a video for how to sew in the submandibular duct stent, and it's got a video for the parotid stent, which is very well done and it's very helpful. I've left in the lacrimal probes as a "stent" to help me identify it, and it's just like five minutes in, it's like half an hour, I'm like trying to put it. It's just like, okay. Yes, it gets frustrating. The stent is very helpful.
…
[Ashley Agan MD]
Yes. That's nice. Once you got your stents, and that's just helping you know where your duct is so that you don't injure it. Right?
[Rohan Walvekar MD]
Yes. There's another advantage to that, Ashley, which I'd like to point out, is that when you try to remove the sublingual gland, you have to make a floor of mouth incision. If you don't know where the stent is, then you tend to make that incision a little bit off the-- like the dome of the floor of the mouth where you expect this submandibular duct to be. What it results in is you'll have just a very small amount of mucosa, then to sew back together at the end of the procedure.
Now that you know where the stent is and you have a visual and a tactile way of identifying it, you can actually make the incision on the middle of the floor of the mouth right over the stent because then that gives you a lot of floor of the mouth mucosa to work with to put things back together.
Complications of Sublingual Gland Removal
While safe and well-tolerated, sublingual gland removal is not without complications. Risk of injury to the lingual nerve or submandibular duct can be minimized with proper surgical technique. In cases of persistent swelling after surgery, patients may be frustrated that their operation did not immediately resolve the issue: counseling must underscore that the operation was successful, and that the body will re-absorb remaining saliva in the post-operative period. As always, infection of the surgical field is possible, though less likely with good oral hygiene and regular Peridex rinses in the post-operative period.
[Ashley Agan MD]
As far as rounding out the conversation, when it comes to complications, what's the most common thing that you deal with and how do you manage that?
[Rohan Walvekar MD]
The most common thing is the ranula not resolving fast enough. If you can't, you should make every effort to decompress the ranula at the time of surgery because that's probably your best chance, so I would say that's the biggest complication of just having the persistent swelling and having to navigate that conversation with patients until it gets all better. The second complication is that sometimes you truly find that there is actually a real cyst or a true cyst beneath the sublingual gland.
It's happened to me a couple of times where I removed the sublingual gland, and I found this well-capsulated cyst which I missed out, then you have to be prepared to make a decision of, can I do this transorally or do I need to come back another time and approach this through the neck? Just keep that in mind, there's always a clinical examination and scans get you to a certain point. Ultimately, when you do surgery, if you're presented with something else, be prepared to be able to step back a little bit, you don't have to finish everything in one day.
Other than that, the conventional complications of submandibular duct injury and lingual nerve injury are real. I think if you pay attention and you do your best, it becomes very, very nominal. Like I would say, lingual nerve paresis is very rare in these situations, less than 1%, and submandibular duct injury, I think if you're careful enough, you would not injure it again, I would say less than 1 to 2%.
Those are kind of pretty much most of the complications that I think about. Then of course, post-operative infection, if you have an open wound in the mouth, and it definitely lends itself to having some infection, so covering with antibiotics and steroids is helpful.
[Ashley Agan MD]
Do you give them any sort of dietary restrictions post-operatively because of that incision in the mouth or they just eat what you want basically?
[Rohan Walvekar MD]
Actually like yes, no, not too many dietary restrictions. I do encourage them to eat from the opposite side. Then of course, rinse the mouth after with the Peridex or whatever they would like, salt water or hot water or warm water gargles, whatever, just to keep the wound clean after every major meal is my recommendation.
Podcast Contributors
Dr. Rohan Walvekar
Dr. Rohan Walvekar is clinical professor of head and neck surgery with LSU in Metairie, Louisiana.
Dr. Ashley Agan
Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.
Dr. Gopi Shah
Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2023, June 8). Ep. 115 – Management of the Plunging Ranula [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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