This patient was seen on referral at the maxillofacial department complaining of an intermittent lump under the tongue. His general dentist had referred him, suggesting that this was a salivary gland.
On examination, there was a large, raised, fluctuant, bluish swelling under the tongue towards the right side, and the treatment plan was to excise this lump and carry out a
histological investigation.
The provisional diagnosis was that of a ranula. This is a mucocele found under the tongue and found within the lining mucosa.
The patient required a general anaesthesia due to the level of surgery because use of local alone would have been inadequate. An oral tube was placed to enable a patent airway to be kept. The area of surgery was infiltrated with local anaesthetic to provide a locally acting vaso-constrictor as well as providing a post-operative anaesthesia for the recovery period.
A suture was placed through the tip of the tongue so that it could be retracted effectively (this is held taught by the assistant and enables good access to the surgical field). In addition, the jaws were held open by a suitable mouth prop.
The lesion was gradually exposed and dissected from the underlying tissues. Blunt and sharp dissection was used to separate the ranula from the sub-lingual tissues and reduce the amount of unnecessary tissue damage.
The lesion was removed in its entirety, taking care not to leave any of the lining behind, while the muscle fibre of the tongue was clearly visible. Blunt dissection reduced
the risks of iatrogenic damage to adjacent structures such as the lingual artery.
Marsupialisation of the wound was carried out by diathermy and resorbable sutures (3.0 Viacryl 9929). The area was not fully closed to enable it to form granulation tissue and also to prevent reformation. The patient was given post-operative Augmentin and a Chlorhexidine mouthwash.
At two weeks the patient was healing well and was then discharged back to the referring dental practitioner. No further follow up was indicated.
The cause of this ranula was not known but it is probable that it was induced by trauma to the area. No evidence of dysplasia or malignancy was found, chronic inflammation with macrophages surrounding spilled saliva was noted. It may have been a foreign body reaction to saliva within connective tissues. The lesions do not recur following complete surgical excision.
