3Extravasation mucocele The leakage of fluid from the ducts or acini into the surrounding tissueเกิดจาก physical trauma ทำให้มีการฉีกขาดของductsHx of rupture, collapse & refilling90% of salivary mucoceleChildren, young adult (peak in second decade)
4Extravasation mucocele Histopathology :mucin-filled cystic cavitygranulation tissue lining surrounded by a condensation of connective tissue with varying amounts of inflammation & vascular engorgementNo epithelium lining - - Pseudocyst
5Retention mucocelePartial obstruction of duct ทำให้ขวางการหลั่งน้ำลาย เกิดเป็น ductal dilation & surface swellingอาจเกิดจาก low-grade chronic superficial irritation ได้พบน้อยกว่า extravasation type> 50 years of age
17CURRENT THERAPY : Mucoceles and Ranulas Harold D. Baurmash ,DDS J Oral Maxillofac Surg61 : , 2003
18Surgical Technique for the Management of Accessory Salivary Gland Mucoceles Lip, cheek, and palateTongue
19Lip, cheek, and palateSmall lesion: completely excised, include the associated salivary gland tissue & marginal glands before primary closureModerate sized lesion: dissection of the mucocele along with the servicing mucous glands
20Lip, cheek, and palate Large lesion: Marsupialization excision problematic & risk vital structure # labial branch of mental nerveReducing recurrence remove any projecting peripheral salivary gland before placement of interrupted marginal suturesAvoid injury to the other glands & ducts surgical injury is another cause of recurrence
21Lip, cheek, and palateNonmucous retention cyst involving the opening of Stensen’s duct :unroof the cystinsert a lacrimal probe into the duct lumen before the duct margins are sutured to the adjacent mucosa with fine interrupted gut sutures (Sialodochoplasty)F/U care - - salivary stimulating foods & duct dilation using lacrimal probe
23Tongue Anterior lingual gland (Gland of Blandin-Nuhn): located on the inferior surface of tongue close to apex & midlinecovered by thin mucous membranea compact package of smaller glands that open with several ducts
24Tongue Small lesion: completely excised & primary closed Moderate to large lesion:unroof the lesion along its entire periphery to visualizeremove all of the glands present
25Tongue Moderate to large lesion: a tongue-retracting suture at tip of tongue1-cm longitudinal incision through mucosa0.25-inch plain gauze - - packed into cavity to restore the original peripheral configurationunroof lesion & remove all glandular tissuemucosa is underminedprimary closure
27Management of Ranula & Ranula-Like Lesions in the Oral Floor Simple marsupialization -> disfavor because of high recurrent rate( %)Crysdale et al ,Catone et al & Bridger et al: “sublingual gland removal should be the primary treatment of all ranula”
28Unroofing -> drainage of it contents Inferior compression by tongue during function will force the opposing granulation tissue walls together -> rapid healing with minimum fibrosis.Not eliminate source of leakage -> recurrence at a higher rate than reported
292 reasons for reconsidering sublingual gland removal as primary treatment 1.A number situations present as ranula that do not arise from the sublingual gland.2.A slight variation to the standard marsupialization procedure can reduce the incident of recurrence to 10% to 12%.
30Treating Ranula-Like Lesion Not Arising From the Body of the Sublingual Gland Mucocele of the incisal glandRetention cyst of Wharton’s ductSubmandibular duct injury with salivary fluid leakageRetention cysts of the sublingual gland
31Mucocele of the incisal gland Incisal gland: small group of mucous accessory glands on the floor of oral cavity behind lower incisorstreated with unroofing & removal of all glandular tissue with or without peripheral margin suturing
32Retention cyst of Wharton’s duct Small(0.5cm) to moderately sized(1.5cm) superficial Cyst-like lesions.Area of caruncular sublingualis extending posteriorly along the course of plica sublingualis.
33- May simulate retention cysts of the ducts of Rivini. - Examination of cystic secretions help to differentiate- Wharton’s duct retention cysts -> assosiated with obstructive submandibular gland symptoms & never larger than 1.5 cm.
34Treatment procedure- Unroofing the cyst, inserting lacrimal probe into duct lumen & sialodochoplasty- Postoperative care -> sour food & ductal dilation with probes.
35Submandibular duct injury with salivary fluid leakage - Iatrogenic injury to antr section of wharton’s duct.Treatment- Locate the damaged duct after excising overlying mucosa.
36- Isolate the duct & milk the gland -> show the extent of injury. - SialodochoplastyLongitudinal incision(1-1.5 cm) in supr wall of duct, postr to the leakageInsert lacrimal probe into lumen, directed toward the gland.
37Suture the margins of duct to adjacent mucosa with 2 gut sutures Single suture -> placed through supr wall at proximal end of incision to engage overlying mucosaPostoperative care
38Retention cysts of the sublingual gland Small to moderate sizeTreatment : unroofing with or without peripheral suturesAcini -> atrophy or secrete through Bartholin’s ductRarely recur
39Treating Ranula from the body of the sublingual gland “Why the majority of large ranulae which originate from the body of the sublingual gland, develop without any history of trauma?”
40Harrison & Garrett:-effect of ligating the sublingual duct in cats with the chorda tympani nerve intact.-In all cases, initial extravasation of mucus -> first 20 days-One half developed mucoceles-Duct obstruction led to the extravasation of mucous from ruptured acini rather than from duct leakage
41Glen, a veterinarian:-Sialograms on dogs with ranulae-Ducts showed no evidence of leakage
42Trauma -> initiating factor in ranula Most cases -> iatrogenicMost common cause: after sialolithomy>>improper incisional design or excessive trauma to glandWharton’s duct -> on medial surface of sublingual glandIncision->medial & parallel to the plica sublingualis
43Incision lateral to the plica-> injure the gland-> ranula on lateral of gland Correct incision -> dissection at antr portion of duct(supr in oral floor)Excessive glandular disruption->ranula medial to glandMucoceles develop up to 3 months after stone removal
44Harrison & Garrett:One half of cats failed to develop mucocelesShowed severe inflammatory reaction # macrophagesExtensive connective tissue response sealed the leakage-> atrophy of acini
45This observation was the rationale for modifying the standard marsupialization technique to decrease recurrence rateAdding gauze packing into cavity after unroofing -> pressure of pack seals the leak.
46Refined marsupialization tectnique with packing Insert lacrimal probe into wharton’s duct for protectionUnroof the cyst.Cavity should be packed to its depthInterrupted suture around margins.Keep the packing in place 7-10 days
48Variations of the Deep Ranula Superficial dissecting ranula- -bilateral & exceptionally large in sizeExcessive amounts of mucous leakage & more resistance inferiorly -> excessive superior pressureBut origin is always unilateral and the ranula arises from deep medial surface of sublingual glandThe side of origin appear a bit more prominent
50Procedure- Place tongue sutureHorizontal mucosal incision across midlineUnroof the cystInsert gauze packing to the full depth of the site of originMucosal margins are sutured with interrupted absorbable sutures.
51Plunging ranula:Large perforation of mylohyoid muscle -> fluid enter the submadibular spaceLarge external swelling with intraoral mass in the oral floorCT or MRI -> aid in diagnosis
53Recommended primary treatment->Removal of sublingual gland. Additional indications:Recurrent ranula after a single marsupialization with packingHypertrophied sublingual glands that interfere with prosthetic reconstruction
54TechniqueSublingual gland-> intraoral removalPrimary attention – Avoid injury to lingual nerve or Wharton’s ductInsert lacrimal probe before incision and keep in place for entire procedure -> make the duct identifiableLongitudinal incision posteroanterior direction midway between plica sublingualis & lingual of mandible (2nd molar to cuspid area)
56Dissection begins on lateral side of the antr 2/3 of gland and is carried down to surface of mylohyoid musclePlace several retracting suture to facilitate the dissection of medial surface of the antr 2/3 of glandMoistened gauze pad or “peanut” in front of elevator -> safe blunt dissectionUse retraction sutures to lift gland superiorly & anteriorly
57Continue blunt dissection on medial postr portion of gland until lingual nerve is identified & isolatedRemove the gland from oral floorafter 1 week of healing, use lacrimal probe to prevent ductal stenosis
58ReferencesDym H, Ogle OE: Atlas of Minor Oral Surgery. Philadelphia, W.B.Saunders,2001Bailey BJ: Surgery of the oral cavity. 1989Yoel J: Pathology and Surgery of the salivary glands. Thomas ,1975Baurmash HD: Mucoceles and Ranulas. J Oral Maxillofac Surg 61: ,2003
59ผศ.ทพ.อนันต์ พงศ์สุวารียกุล Special Thanksผศ.ทพ.อนันต์ พงศ์สุวารียกุล