MUCOCELE

1
MUCOCELERANULA
2
MUCOCELE

• ??? ?????????????????????????????????????????
  ???????????????????????????? minor salivary gland
• ???????? 2 ???????????????????? ???
• 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
• ??????? physical trauma ???????????????????ducts
• 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
Retention mucocele

• Partial obstruction of duct ??????????????????????
  ? ???????? ductal dilation surface swelling
• ?????????? low-grade chronic superficial
  irritation ???
• ?????????? extravasation type
• gt 50 years of age

6
Retention mucocele
Histopathology

• ????? extravasation type
• ??? cavity ?????? ductal epithelial cells
  stratified squamous epith. , columnar,cuboidal -
  - True cyst

7
???????????????

• Soft , painless swelling
• Translucent deep blue to normal pink
• ????????? lower lip , cheek ,palate
• ??????????? ventral of tongue, incisal gland,
  retromolar pad

8
???????????????

• Rarely present significant problem
• Discomfort, interference with speech/masticating/s
  wallowing external swelling depend on size
  location

9
Treatment

• ???????????????????? minor salivary gland
  ?????????????

10
RANULA

• ??? mucocele ???????????????? floor of mouth
• ??????????? sublingual gland
• ??????? obstruction or disruption of sublingual
  ducts

Plunging ranula(Deep ranula)

• ??? ranula ????????????????????? mylohyoid muscle
  ????????? fascial plane of neck

11
(No Transcript)
12
???????????????l

• Unilateral, fluctuant, soft tissue mass ??? floor
  of mouth
• Bluish, translucent swelling
• painless

Histo

• Most - - extravasation type
• ?????????? mucous retention type ??????????

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
Whartons 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

• ?????????????????????????? (unroofing
  procedure)
• ???????????????????????????
• ???????????????????????????????????
  ??????????????????????? ??????????????????????????
  ?????????

16
Marsupialization

• ???????????????? mucosa ??????????????????????????
  ?????????????????????????????
• ??????? ?????? mucosa ????????????????????????????
  ???
• ?????????????????? ????????????????????????????
  ??????????????????????????????????????????????????
  

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
  Stensens 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

22
(No Transcript)
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

26
(No Transcript)
27
Management of Ranula Ranula-Like Lesions in the
Oral Floor

• Simple marsupialization -gt 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 -gt drainage of it contents
• Inferior compression by tongue during function
  will force the opposing granulation tissue walls
  together -gt rapid healing with minimum fibrosis.
• Not eliminate source of leakage -gt 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 Whartons 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
• treated with unroofing removal of all glandular
  tissue with or without peripheral margin suturing

32
Retention cyst of Whartons 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 - Whartons duct retention
cysts -gt 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 -gt sour
food ductal dilation with probes.
35
Submandibular duct injury with salivary fluid
leakage
- Iatrogenic injury to antr section of whartons
duct. Treatment - Locate the damaged duct after
excising overlying mucosa.
36

• - Isolate the duct milk the gland -gt show the
  extent of injury.
• - Sialodochoplasty
• Longitudinal incision(1-1.5 cm) in supr wall 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 -gt 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 -gt atrophy or secrete through Bartholins
  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 -gt 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 -gt initiating factor in ranula
• Most cases -gt iatrogenic
• Most common cause after sialolithomygtgtimproper
  incisional design or excessive trauma to gland
• Whartons duct -gt on medial surface of sublingual
  gland
• Incision-gtmedial parallel to the plica
  sublingualis

43

• Incision lateral to the plica-gt injure the
  gland-gt ranula on lateral of gland
• Correct incision -gt dissection at antr portion of
  duct(supr in oral floor)
• Excessive glandular disruption-gtranula 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-gt 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
  -gt pressure of pack seals the leak.

46

• Refined marsupialization tectnique with packing
• Insert lacrimal probe into whartons 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

47
(No Transcript)
48

• Variations of the Deep Ranula
• Superficial dissecting ranula- -bilateral
  exceptionally large in size
• Excessive amounts of mucous leakage more
  resistance inferiorly -gt 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

49
(No Transcript)
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.

51

• Plunging ranula
• Large perforation of mylohyoid muscle -gt fluid
  enter the submadibular space
• Large external swelling with intraoral mass in
  the oral floor
• CT or MRI -gt aid in diagnosis

52
(No Transcript)
53

• Recommended primary treatment-gtRemoval of
  sublingual gland.
• Additional indications
• Recurrent ranula after a single marsupialization
  with packing
• Hypertrophied sublingual glands that interfere
  with prosthetic reconstruction

54

• Technique
• Sublingual gland-gt intraoral removal
• Primary attention Avoid injury to lingual nerve
  or Whartons duct
• Insert lacrimal probe before incision and keep in
  place for entire procedure -gt make the duct
  identifiable
• Longitudinal incision posteroanterior direction
  midway between plica sublingualis lingual of
  mandible (2nd molar to cuspid area)

55
(No Transcript)
56

• Dissection begins on lateral side of the antr 2/3
  of gland and is carried down to surface of
  mylohyoid muscle
• Place several retracting suture to facilitate the
  dissection of medial surface of the antr 2/3 of
  gland
• Moistened gauze pad or peanut in front of
  elevator -gt safe blunt dissection
• Use retraction sutures to lift gland superiorly
  anteriorly

57

• Continue blunt dissection on medial postr portion
  of gland until lingual nerve is identified
  isolated
• Remove the gland from oral floor
• after 1 week of healing, use lacrimal probe to
  prevent ductal stenosis

58
References

• Dym H, Ogle OE Atlas of Minor Oral Surgery.
  Philadelphia, W.B.Saunders,2001
• Bailey BJ Surgery of the oral cavity. 1989
• Yoel J Pathology and Surgery of the salivary
  glands. Thomas ,1975
• Baurmash HD Mucoceles and Ranulas. J Oral
  Maxillofac Surg 61369-378,2003

59
Special Thanks
??.??.?????? ??????????????