Diagnosis and treatment for Breakthrough Clinical oral pathology case: No. 12

Kevin J. Connor, DDS, MD, gives his diagnosis and recommended treatment for Breakthrough Clinical's oral pathology case from last month. A healthy 21-year-old female presents to the dentist's office referred from her primary-care physician for evaluation of a “lump” under her tongue that has been present for about two months. The lump has been very slowly growing, totally asymptomatic. The patient did say she noticed it “popped” at one time, but it came back a few weeks later. The physician thought it merited a further evaluation from a dental professional. Read complete details of the case and view photos.

Mar 1st, 2016
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This article first appeared in the newsletter, DE's Breakthrough Clinical with Stacey Simmons, DDS. Subscribe here.

Last month, I presented this pathology case:

A healthy 21-year-old female presents to the dentist's office referred from her primary-care physician for evaluation of a “lump” under her tongue that has been present for about two months. The lump has been very slowly growing, totally asymptomatic. The patient did say she noticed it “popped” at one time, but it came back a few weeks later. The physician thought it merited a further evaluation from a dental professional.

Read the complete details of the case and view photos here.

Here is my diagnosis and recommended treatment . . .

Differential diagnoses:

  • Ranula
  • Mucocele
  • Benign or malignant salivary gland neoplasm
  • Lymphangioma
  • Oral lymphoepithelial cyst

Definitive diagnosis: ranula

A ranula is a lesion that belongs in the category of “mucous escape phenomenon,” which also includes mucoceles and sialoceles. (1,2) The underlying problem is not one of a cellular pathologic condition, but rather a problem involving tissue trauma overlying a salivary excretory duct and subsequent healing in a malposed position. This subsequent healing of the duct in an incorrect position causes mucous to be extravasated into the oral tissue rather than the oral cavity. The clinical appearance of this phenomenon is typically that of a painless, fluctuant mass that is often translucent, causing it to have a bluish hue.

ALSO BY DR. KEVIN CONNOR |Diagnosis and treatment for Breakthrough Clinical pathology case: No. 5

Ranulas can range in size from small-diameter masses, like that of the CPC presented in this case, to large masses that extend out of the oral cavity. If the damaged outflow tract is posterior to or through the mylohyoid muscle, ranulas can extend into the neck rather than the oral cavity and cause a phenomenon known as a “plunging ranula.”

Treatment for a ranula, in most instances, requires removal of the offending gland, which is the sublingual gland. (2) It has been described to attempt a marsupialization of the fluctuant mass, but is typically met with recurrence of the ranula at a rate of approximately 75%. A correct removal of the gland is a very safe procedure with a very low risk of postoperative complications. Removal of the sublingual gland is well tolerated with almost all patients unaware of the reduction in mucous output.

postoperative photos . . .

In the case presented in this CPC, the area was biopsied given how far onto the ventral tongue the mass lay (most ranulas present on the floor of the mouth), although during the biopsy there was a very easily discernible tract extending inferior to the sublingual gland. The biopsy expectedly returned as a ranula, and the patient was taken to the operating room for removal of the gland. Correct removal of the sublingual gland requires identification of the submandibular duct (Wharton’s duct) and the lingual nerve, which dives under the duct at the posterior extension of the gland. The patient in this case did very well, and the ranula resolved following the removal of the gland.

ALSO BY DR. KEVIN CONNOR |Diagnosis and treatment for Breakthrough Clinical pathology case: No. 8

This article first appeared in the newsletter, DE's Breakthrough Clinical with Stacey Simmons, DDS. Subscribe here.

References

1. Sapp JP, Eversole LR, Wysocki GP. Contemporary Oral and Maxillofacial Pathology. St. Louis, MO: Mosby; 1997:320–323.
2. Marx RE, Stern D. Oral and Maxillofacial Pathology. Chicago, IL: Quintessence; 2003:511–515.

Kevin J. Connor, DDS, MD, is a graduate of Marquette School of Engineering with a BS in biomedical engineering. He earned his DDS degree from the Marquette University School of Dentistry in 2004. Dr. Connor went on to complete medical school at the Louisiana State University Health Sciences Center in 2007, and completed a one-year general surgery internship in 2008. He completed his oral surgery training in 2010 at LSU, and currently is in private practice outside of Milwaukee, Wisconsin. Dr. Connor’s surgical interests include dentoalveolar trauma, reconstructive surgery, and the surgical treatment of diseases of the temporomandibular joint. He is a member of the American Association of Oral and Maxillofacial Surgeons, American Medical Association, American Dental Association, Waukesha County Dental Society, Jefferson County Dental Society, and the Wisconsin Dental Association. Dr. Connor is a diplomate in the American Board of Oral and Maxillofacial Surgeons.

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