(a) Aspiration and replacement with OK-432 solution (Ogita's original method)
To treat the plunging type of ranula, about 1 ml of 1% lidocaine-hydroclorate was injected into the skin over the submandibular swelling site for local anesthesia. Then the cyst was punctured using a syringe with an 18 G needle and the intracystic fluid was aspirated. When we treated the oral floor type of ranula, we punctured the mucous membrane of the oral floor at a distance from the cyst wall in order to avoid outflow of OK-432 from the puncture hole. The intracystic fluid of ranula was highly viscous, so it was necessary to use a large needle for aspiration. When you treat lymphangioma or median cervical cyst, you don't need to use big needle. In order to aspirate the contents sufficiently, compression of the cyst was sometimes needed.
2) Intracystic injection of OK-432
After determining the capacity of the lesion, a sufficient quantity of OK-432 (Picibanil; Chyugai Pharmaceutical Co., Tokyo, Japan) diluted with saline (0.1 KE/ml, which means 0.01 mg/ml) were prepared. With the same needle used for aspiration, we injected OK-432 solution into the cyst by changing the syringe. In a few cases OK-432 was injected extracystically, so careful maintenance of the needle position during exchange of the syringe was necessary. There was no resistance, in case of successful injection into the cyst cavity and injection of the same quantity of OK-432 solvent was possible.
Intracystic fluid of ranula. It is very viscous. These are intracystic fluids from various patients with ranula. (please click)
From left: Aspiration of cyst fluid, Cyst fluid, Solved OK-432 to inject, Just after treatment
This photograph is taken during supuraclavicular lymphangioma treatment. Her friend took this picture.
(b) Highly concentrated OK-432 injection without aspiration
In case of oral floor ranula, I usually inject highly concentrated OK-432 without aspiration. In case of small cyst (<2 cm), 0.5 KE of OK-432 and in case of large cyst (>2 cm), 1.0 KE of OK-432 was diluted with 0.1 to 0.2 ml of saline. And, it was injected with 27 G needle without aspiration of intracystic fluid. This method is very easy even if the patient is an infant.
Only inject 0.2 ml with this small needle.
Usually, these treatment can be done as out patient basis, no need of hospitalization. But, for lymphangioma in head & neck area, short stay at the hospital is recommended (please click).
OK-432 is a penicillin killed bacteria (streptococcus), inflammatory responses (fever up, local pain) are observed after treatment.To treat fever, we gave analgesics for 3 days to all patients and patients have it only when fever up was observed. Analgesic suppositories were also used as needed. We treated the initial four cases with hospitalization for 4 to 5 days. After the safety of the procedure had been established, we treated other almost 100 cases as outpatients. We examined them on day 2, day 7, day 14, and day 28, day 42 after OK-432 injection and judged the final response between 4 to 6 weeks. If the response was insufficient, we repeated the same therapy with 1.5 times increased OK-432 again. Patients from distant place, examinations can be substituted by sending photographs by e-mail.
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