MUCOCELE & RANULA

1. MUCOCELE&RANULA

2. MUCOCELE คือ ช่องว่างภายในเนื้อเยื่อที่มีน้ำลายขังอยู่ เป็นถุงน้ำที่เกิดสัมพันธ์กับminor salivary gland แบ่งเป็น 2 ชนิดตามสาเหตุการเกิด คือ Extravasation mucocele (Mucous extravasation cyst) 2. Retention mucocele (Mucous retention cyst )

3. Extravasation mucocele • The leakage of fluid from the ducts or acini into the surrounding tissue • เกิดจาก physical traumaทำให้มีการฉีกขาดของducts • Hx of rupture, collapse & refilling • 90% of salivary mucocele • Children, young adult (peak in second decade)

4. Extravasation mucocele Histopathology : • mucin-filled cystic cavity • granulation tissue lining surrounded by a condensation of connective tissue with varying amounts of inflammation & vascular engorgement • No epithelium lining - - Pseudocyst

5. Retentionmucocele • Partial obstruction of duct ทำให้ขวางการหลั่งน้ำลาย เกิดเป็น ductal dilation & surface swelling • อาจเกิดจาก low-grade chronic superficial irritation ได้ • พบน้อยกว่า extravasation type • > 50 years of age

6. Retention mucocele Histopathology : • คล้ายextravasation type • แต่ cavity บุด้วย ductal epithelial cells : stratified squamous epith. , columnar,cuboidal - - True cyst

7. ลักษณะทางคลินิก • Soft , painlessswelling • Translucent deep blue to normal pink • พบบ่อยที่lower lip , cheek ,palate • อาจพบได้ที่ ventral of tongue, incisal gland, retromolar pad

8. ลักษณะทางคลินิก • Rarely present significant problem • Discomfort, interference with speech/masticating/swallowing & external swelling depend on size& location

9. Treatment • ตัดรอยโรคออกพร้อมกับ minor salivary gland ที่เกี่ยวข้อง

10. RANULA • คือ mucoceleที่เกิดในตำแหน่งfloor of mouth • สัมพันธ์กับsublingual gland • เกิดจาก obstruction or disruption of sublingual ducts Plunging ranula(Deep ranula): • คือ ranula ที่อยู่ลึกลงไปต่ำกว่า mylohyoid muscle และตามแนว fascial plane of neck

12. ลักษณะทางคลินิกl • Unilateral, fluctuant, soft tissue mass ที่ floor of mouth • Bluish, translucent swelling • painless Histo: • Most - - extravasation type • แต่ก็พบแบบ mucous retention type ได้เช่นกัน

13. Most common origin of ranula 1. Deeper area of the body of sublingual gland 2. Retention cysts from Ducts of Rivini 3. Retention cysts of the opening of Wharton’s duct

14. Treatment • Removal of sublingual gland along with excision of the cyst • Marsupialization with sublingual gland excision • Deep ranula : • sublingual gland removal along with excision of the cyst

15. Marsupialization • คือการเปิดฝาของถุงน้ำออกไป(unroofing procedure) • เป็นการลดความดันภายในถุงน้ำ • พิจารณาทำในกรณีที่มีถุงน้ำขนาดโตมาก ยากแก่การควักออกทั้งหมด เพราะอาจทำอันตรายต่ออวัยวะข้างเคียง

16. Marsupialization • โดยการตัดเอาส่วน mucosaที่ปกคลุมถุงน้ำออกไปพร้อมกับผนังถุงน้ำที่อยู่บริเวณนั้น • จากนั้น ขอบของ mucosa จะถูกเย็บติดกับขอบของผนังถุงน้ำ • ควรเปิดฝาเป็นวงกลม และให้มีขนาดโตเท่าที่จะทำได้ เพื่อป้องกันการเจริญเติบโตของผนังถุงน้ำมาติดกันอีก

17. CURRENT THERAPY : Mucoceles and Ranulas Harold D. Baurmash ,DDS J Oral Maxillofac Surg 61 : 369-378, 2003

18. Surgical Technique for the Management of Accessory Salivary Gland Mucoceles • Lip, cheek, and palate • Tongue

19. Lip, cheek, and palate Small lesion: completely excised, include the associated salivary gland tissue & marginal glands before primary closure Moderate sized lesion: dissection of the mucocele along with the servicing mucous glands

20. Lip, cheek, and palate • Large lesion: Marsupialization • excision problematic & risk vital structure # labial branch of mental nerve • Reducing recurrence remove any projecting peripheral salivary gland before placement of interrupted marginal sutures • Avoid injury to the other glands & ducts surgical injury is another cause of recurrence

21. Lip, cheek, and palate • Nonmucous retention cyst involving the opening of Stensen’s duct : • unroof the cyst • insert 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

23. Tongue • Anterior lingual gland • (Gland of Blandin-Nuhn): • located on the inferior surface of tongue close to apex & midline • covered by thin mucous membrane • a compact package of smaller glands that open with several ducts

24. Tongue • Small lesion: • completely excised & primary closed • Moderate to large lesion: • unroof the lesion along its entire periphery to visualize • remove all of the glands present

25. Tongue • Moderate to large lesion: • a tongue-retracting suture at tip of tongue • 1-cm longitudinal incision through mucosa • 0.25-inch plain gauze - - packed into cavity to restore the original peripheral configuration • unroof lesion & remove all glandular tissue • mucosa is undermined • primary closure

27. Management of Ranula & Ranula-Like Lesions in the Oral Floor • Simple marsupialization -> disfavor because of high recurrent rate(61 - 89%) • Crysdale et al ,Catone et al & Bridger et al: “sublingual gland removal should be the primary treatment of all ranula”

28. Unroofing -> 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

29. 2 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%.

30. Treating Ranula-Like Lesion Not Arising From the Body of the Sublingual Gland • Mucocele of the incisal gland • Retention cyst of Wharton’s duct • Submandibular duct injury with salivary fluid leakage • Retention cysts of the sublingual gland

31. Mucocele of the incisal gland • Incisal gland: small group of mucous accessory glands on the floor of oral cavity behind lower incisors • treatedwith unroofing & removal of all glandular tissue with or without peripheral margin suturing

32. Retention 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.

34. Treatment procedure -Unroofing the cyst, inserting lacrimal probe into duct lumen & sialodochoplasty - Postoperative care -> sour food & ductal dilation with probes.

35. Submandibular 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 theextent of injury. • -Sialodochoplasty • Longitudinal incision(1-1.5 cm) in suprwall of duct, postr to the leakage • Insert lacrimal probe into lumen, directed toward the gland.

37. Suture 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 mucosa • Postoperative care

38. Retention cysts of the sublingual gland • Small to moderate size • Treatment : unroofing with or without peripheral sutures • Acini -> atrophy or secrete through Bartholin’s duct • Rarely recur

39. Treating 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?”

40. Harrison & 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

41. Glen, a veterinarian: -Sialograms on dogs with ranulae -Ducts showed no evidence of leakage

42. Trauma-> initiating factor in ranula • Most cases -> iatrogenic • Most common cause: after sialolithomy>>improper incisional design or excessive trauma to gland • Wharton’s duct -> on medial surface of sublingual gland • Incision->medial & parallel to the plica sublingualis

43. Incision 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 gland • Mucoceles develop up to 3 months after stone removal

44. Harrison & Garrett: • One half of cats failed to develop mucoceles • Showed severe inflammatory reaction # macrophages • Extensive connective tissue response sealed the leakage-> atrophy of acini

45. This observation was the rationale for modifying the standard marsupialization technique to decrease recurrence rate • Adding gauze packing into cavity after unroofing -> pressure of pack seals the leak.

46. Refined marsupialization tectnique with packing • Insert lacrimal probe into wharton’s duct for protection • Unroof the cyst. • Cavity should be packed to its depth • Interrupted suture around margins. • Keep the packing in place 7-10 days

48. Variations of the Deep Ranula • Superficial dissecting ranula- -bilateral & exceptionally large in size • Excessive amounts of mucous leakage & more resistance inferiorly -> excessive superior pressure • But origin is always unilateral and the ranula arises from deep medial surface of sublingual gland • The side of origin appear a bit more prominent

50. Procedure • - Place tongue suture • Horizontal mucosal incision across midline • Unroof the cyst • Insert gauze packing to the full depth of the site of origin • Mucosal margins are sutured with interrupted absorbable sutures.