Combined type ranula (5)

She had swelling both oral floor and right neck. At first, she had only oral ranula. She got surgery from mouth two years ago. After surgery, her ranula reccured as combined type. She was recommended to be removed her ranula by surgery. She found this home page and came to me.

White area in MRI is ranula. Ranula was spreded deeply and widely. Cyst fluid was yellowsh mucous. This was typical for ranula.

I punctured her right neck and aspirated 5 ml of cyst fluid then injected OK-432 1 KE susupended with 4 ml of saline. Her right neck was markedly swollen one day after OK-432 injection. This was good response. But, the effect of the 1st treatment was not enough.

The 2nd OK-432 injection was performed 12 weeks after the 1st treatment. I punctured her neck and oral floor and aspirated 25 ml of cyst fluid. Then, I injected OK-432 1KE susupended in 2 ml of saline. Regrettably, 5 days after OK-432 injection, her oral floor was raptured. So, it was not effective. 5 feeks after the 2nd OK-432 injection, aspiration of cyst fluid was added. But, 2 months after treatment, her neck swelling was returned to the same level of pretreatment.

So, the 3rd treatment was performed. I puctured her right neck and aspirated 18 ml of cyst fluid, then injected OK-432 1 KE susupended with 4 ml of saline. From the next day to 1 week after treatment, her right neck was markedly swollen. Her swelling was reduced at 6 weeks after treatment. But, the swelling was still remained. After that, her ranula repeated growth swelling and spontaneous raopture. But, at 1 year after treatment, her neck swelling moved to under her right ear and became hard. After several days, her neck and oral floor swelling was completely disappeared. After 6 months, there was no recurrence.

She needed three times of OK-432 injection and long time. But, her ranula was cured without any scar formation. She came from Kanto area, 300 miles from Yamagata. Total vist times were 4. The first treatment was performed as staying over night, the lest 3 treatments were performed in a day.

Important points for this patient are
@1, She had a surgery for small oral ranula but recurred as big combined ranula.
@2. She needed three OK-432 therapy.
@3. Why and how her ranula was cured in a long time?
About 1, Removal or marspialization of ranula does not promise cure. Ranula is a leakage of saliva, so if the leakage did not stop, it will recur despite complete removal is performed. It is sometimes experienced that oral ranula turned to be plunging ranula after surgery. Plunging ranula 1, 10, 14, 15, and combined ranula 3 of this home page were also so. After operation, the mucosa of oral floor became hard (scar formation). So, leaked saliva cannnot go upward, then saliva goes to downward. Regrettably, still now, it is written in some medical textbooks that complete removal is necessary for prevention of recurrence. The strategy of ranula treatment is to stop leakage from sublingual gland.
About 2, if there are weak lesions of skin or mucous membrane after surgery, rapture sometimes occurs after OK-432 injection. Many doctor think that if OK-432 therapy was performed, the following operation will be difficult. But, it is not true. Removal of sublingual gland can be done with no interference after OK-432 therapy. OK-432 therapy must be done before surgery. After operation, OK-432 therapy becomes difficult.
About 3, The size of ranula is determined by the balance between increase factor (saliva leakage) and decrease factors (compression, absorption), If the balance lean to decrease, spontaneous regression occurs. The same case was reported by other physicians. ( A case of plunging ranula cured very slowly by local injection of OK-432. Japanese. Kinki medical Journal. vol. 34; 143-147, 2009)

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