Here’s
something you don’t see every day. A guy
came to me some years back, with a mass in his neck, below his jaw. It was soft, nonpainful and had been present
for several years. It was growing slowly
and becoming more noticeable, such that his wife noticed it, and urged him to
see a doctor. Being a male with the male
tendency of not listening to their womenfolk--a trait imparted to males by
design—he naturally did not heed this advice.
His lack of foresight—the result of the punier Y chromosome which carries
the genes for common sense, so I’ve been told by several females—disallowed him
to appreciate the consequences of disobeying the spouse, and he found himself
being dragged by the ear to my office by his disgruntled better-half.
 |
| soft bulge below jaw (preop surgical outline) |
Such is the state I found him, with painless neck mass and sore ear. The mass looked and felt rather benign, but was becoming disfiguring and surgery was desired. Upon CT imaging, this appeared to be a plunging ranula.
A
ranula is a cyst filled with mucous and saliva (or mucous retention cyst,
a fancy medical term docs use to justify all those years in school and six-figure
student loans) which arises for the sublingual gland, a salivary gland
found just beneath the floor of the mouth under the tongue. Within the gland itself are tinier microscopic
glands lined by cells that secrete saliva or mucous (there is a difference, but
we go into that). Each of these smaller
glands sends tiny ducts to a main duct which drains into the mouth. If one of these tinier ducts gets blocked,
there is no outlet for the secreted fluid, and the small gland eventually expands
like a balloon as it continually fills with fluid. So that’s the etiology—the cause
in medical terms.
 |
| Normal anatomy |
Most of the time, the ranula forms on the top part of the gland and expands upwards into the mouth. A grayish soft mass can be seen under the tongue, and removal is done transorally (the fancy Latin term meaning “through the mouth”).
However,
the ranula can form on the underside of the sublingual gland and pushes itself
downward into the neck. Such was the
case with this patient. The ranula can also
push the other salivary gland found beneath the jaw, the submandibular gland,
farther down. Removal in this case is
more complicated, requiring a transcervical (“through the neck”) approach
via a neck incision and sometimes removal of the submandibular gland itself. Part of the sublingual gland is also removed
if the cyst is embedded into it, which risks creating a defect in the floor of
the mouth, which can be repaired with a careful water-tight closure.
Plunging ranulas are uncommon and can occur in any age group. I’ve operated on only six of these, ages 11 to 64.
This
guy was 61 yrs old, and he did well after surgery. I believe it was his 3rd wife that
dragged him into the office. Perhaps the
previous two ex-spouses mentioned his neck and he failed to comply, but I never
asked.
©Randall
S. Fong, M.D.
For more topics on
medicine, health and the weirdness of life in general, check out the rest of
the blog site at randallfong.blogspot.com
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