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SUBLINGUAL RANULA: CASE REPORT AND REVIEW OF LITERATURE

Article · June 2015

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CASE REPORT

SUBLINGUAL RANULA: CASE REPORT AND REVIEW OF LITERATURE

Karandeep Singh Arora1,*, Prabhpreet Kaur2, Richa Modgil3, Lalit Singh Negi4
1,3DaswaniDental College & Research Centre, Kota, Raj.
2B.R.S. Dental College & General Hospital, Panchkula, Haryana
4Surendra Dental College & Research Institute, Sri Ganganagar, Raj.

*Corresponding Author:
Email: drkaranarora@yahoo.com

ABSTRACT:
A ranula can be defined as a mucous filled cavity, a mucocele located in the floor of the mouth with the sublingual
gland. It resembles a frog’s under belly/air sac, which is translucent. Based on clinical features they are of various types. This
condition should be accurately diagnosed as it can mimic other potent pathologies. Advanced imaging like CT, MRI are also
useful for diagnostic procedures. Surgery and medicine are the treatment options available, more commonly opted is the surgical
treatment because with the medical treatment there are chances of recurrence. Through this paper we highlight a case on ranula
in the floor of the mouth with a review of literature emphasizing the use of the advanced imaging diagnostic methods and
updated medical line of treatment.

Keywords: Ranula, Sublingual gland, pesudocyst

INTRODUCTION
Ranula was first described by Hippocrates.1 diagnosed as “ranula”. The patient was referred for
Formation of the ranula is due to rupture of the radiographic examination, which showed no signs of
excretory duct which is followed by extravasation obstruction. After all clinical and preoperative
and salivary accumulation into the surrounding tissue evaluations excision of ranula along with the
which forms a pseudocyst that lacks epithelial sublingual gland was done and patient follow up was
lining.2-3 Clinically ranula is of three types. Most done every week. The excised sample was sent for
common of which is the "Sublingual ranula" which histopathological examination, which revealed
presents as an intraoral sublingual swelling. The predominance of histocytes in the cystic space and on
second commonest is the “Plunging ranula” which is the pseudocystic fibrous connective tissue wall and
located cervically and extend beyond mylohyoid further the central cystic space and the walls
muscle, and those having both cervical and oral composed of loose and vascularized connective tissue
component is known as "sublingual plunging with the sublingual gland. (Fig. 2)
ranula".4 It has an unknown etiology but it may be
seen in association with congenital anomalies,
trauma, and disease of sublingual gland.5 The basic
purpose of this article is to report a case of ranula and
update the medical treatment for the same.

CASE REPORT
A 6 year old girl was brought to the out
patients clinic of the Department of Oral Medicine &
Radiology with a complaint of a growth in the floor
of the mouth, since 1 month, that was interfering with
mastication and speech. History further revealed that
the growth was gradual on onset and progressive in
size and was painless throughout its course. History
of a similar growth but smaller in size when
compared to the present growth, is also reported 6 Fig. 1: Bluish Dome shaped swelling
months back which regressed on itself.
On clinical examination a bluish dome
shaped swelling (Fig. 1) was seen on the left side of
floor of mouth adjacent to 74, 75 measuring 2 x 2 cm
in size which was soft in consistency, compressible,
reducible and fluctuant. After correlating the history
and clinical findings, case was provisionally

Journal of Oral Medicine, Oral Surgery, Oral Pathology and Oral Radiology;2015;1(1):45-47 45
Arora et al. Sublingual Ranula: Case Report and Review of Literature

More often, due to location of the sublingual

gland the ultrasonographic examination is
inconclusive. Computed Tomography examination of
a simple ranula reveals a cystic lesion which may be
rough and ovoid in shape, with a central attenuation
of 10 to 20 HU. The sublingual ranula is located
above the mylohyoid muscle and just lateral to
genioglossus muscle. Anteriorly, it may or may not
extend behind the symphysis, above the genioglossus
muscle and geniohyoid muscle. The most conclusive
and sensitive examination for the sublingual salivary
gland is magnetic resonance imaging (MRI), the
appearance of which is dominated by its high water
Fig. 2: Central cystic space and wall composed of content. Thus, T1-weighted intermediate proton
loose, vascularized connective tissue with the density is low and T2-weighted signal intensity
sublingual gland high.13-14
Histopathologically, ranula consists of a
DISCUSSION & REVIEW central cystic space, which contains mucin and a
The name "ranula" is derived from the Latin pseudocyst wall and is composed of loose and
word “rana” which means "frog" which resembles vascularized connective tissues. Predominantly there
translucent underbelly/air sac of frog. It is defined as is presence of histocytes within the pseudocyst wall,
a mucus filled cavity in relation to sublingual gland which decrease in number over a period of time.
present in the floor of mouth. It appears as tense, There is absence of epithelial tissues in the wall of
dome-shaped vesicle, which is fluctuant and ranula. A histopathological examination of the cystic
characterized by size larger than 2 cm and sometimes wall is mandatory, to rule out the presence of
may present with a bluish hue.6-7 malignant carcinoma arising from the cyst wall and
Ranula accounts for around 6% of oral papillary cystadenocarcinoma of the sublingual
sialocysts and its prevalence is around 0.2 cases of gland, which may mimic ranula.15
1000. Out of all the cases diagnosed as ranula only 1 There are several different methods for the
- 10% are truly retention cysts. The peak age of treatment of ranula. These include excision of the
occurrence of ranula is second decade and normally lesion via an intraoral or cervical approach,
found in children and also young adults. 8 marsupialisation, intra oral excision of the sublingual
Two theories have been proposed regarding gland and drainage and excision along with
the development of ranula. According to the first sublingual gland.
theory it develops as a consequence of mucus Garofalo S et al. in a study evaluated the
extravasation, whereas the second theory proposes effectiveness of orally administered Nickel
mucus retention, both due to rupture or damage of a Gluconate-Mercurius Heel-Potentised Swine Organ
duct of salivary gland.9 But the current review and Preparations D10/D30/D200 for treatment of ranula
opinions support mucus extravasation secondary to without surgery. The mechanism of action of which
developmental factor as ranula are devoid of lining is to stimulate pseudocyst reabsorption and glandular
epithelium.10 repair thus improving the physiologic functioning of
Sometimes ranula may mimic some benign the gland. They concluded that this is an effective
and malignant lesions, so the clinical diagnosis of treatment for ranula and oral mucoceles.16
ranula is very important. The differential diagnosis of A study conducted by Fukase S. et al.
all the clinical types of ranula includes inflammatory, showed a disappearance or marked reduction
neoplastic lesions of major salivary glands except the in ranula size with injection of OK-432. In their
parotid gland, of the lymph nodes, granulomatous study only half of the patients experienced local pain
diseases, diseases of the adipose tissue, thyroglossal or fever which resolved within several days. Intra-
duct cysts, cystic hygroma, dermoid, epidermoid cystic injection therapy with OK-432 is relatively
cysts and laryngocele.11 safe and can be used as a substitute for surgery in the
No specific diagnostic tests are there for treatment of ranula.17
ranula. At times it present as a cystic fluctuant lesion, Sialoendoscopy holds a promising future as
which gradually increases in size with time. The fluid a new and better method for diagnosis, treatment and
contents of ranula are composed of salivary amylase postoperative management of sialadenitis,
and protein in higher contents when compared to sialolithiasis and other obstructive salivary gland
serum. This indicated that ranula originates from diseases.18
sublingual gland as it produces highly protein saliva
in contrast to submandibular gland.12
Journal of Oral Medicine, Oral Surgery, Oral Pathology and Oral Radiology;2015;1(1):45-47 46
 Arora et al. Sublingual Ranula: Case Report and Review of Literature

CONCLUSION
Accurate diagnosis is important for the
effective treatment of ranula. With the introduction of
advanced imaging techniques like CT and MRI, helps
the clinicians in making proper diagnosis and
treatment planning. During surgery there is threat of
injury to the lingual nerve thus surgical approach
should be prevented and the latest medical
management techniques should be advocated.

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Journal of Oral Medicine, Oral Surgery, Oral Pathology and Oral Radiology;2015;1(1):45-47 47

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