Plunging ranula (14)@iVery complicated casej

Left: Before treatment. Right: After treatment

8 years old girl. She came to me because she had suffered from ranula for 3 years.
At first, she had oral ranulas at both sides. She had 2 surgeries from oral cavity with general anesthesia. But, recurred as plunging ranula of both side. After that, she had OK-432 therapy twice. After first OK-432 therapy, ranula was disappeared for 3 months then recurred. The second OK-432 therapy was not effective. At that point, 2 years had passed from the start of treatment.
So, her parents decided to go to Tokyo. She visited a very famous hospital and had a surgery with general anesthesia. The operation was removal of right ranula, right submandibular gland and right sublingual gland. But, ranula was recurred within one month after operation. After that, she had OK-432 therapy. But, rapture occurred at the neck wound of surgery. From the ruptured skin, saliva was always flowing out, so she had to take gauze on her neck for 6 months.

Upper : From Left: Attached with first e-mail, When she first come to my clinic, Cyst Fluid
Lower : From Left: After aspiration, 8 weeks after first aspiration, After 2nd aspiration

Upper left is a photo attached with their parent's first e-mail. There was a fistula on the operation scar. She came to me one month after first e-mail. The fistula was spontaneously closed with crust a few days ago. MRI showed that ranulas were existed on both side. It was obvious that rapture would occur if I inject OK-432. So, I decided to wait until the scar became strong. Only aspiration was done, the first day and 8 weeks after.

Upper : From Left: Before treatment, 2 days, 6 days after treatment
Lower: From Left: 9 days, 12 days, 15 days, 24 days after OK-432 injection

This is a course after treatment. We waited 3 months and then started to treat. For this patient alone, I treated her in hospital for 2 nights for fear of air way stenosis. I punctured her right neck and aspirated 30 ml of cyst fluid, then injected 1 KE of OK-432. Upper middle is 2 days after treatment. Her neck was markedly swollen but air way stenosis was not observed. So, she discharged 2 days after treatment, and then her father took photographs and sent me. On day 6 and 9, the swelling of anterior neck was obvious. After that swelling of anterior neck was gradually reduced. But, the swelling of her left chin was gradually increased. This means that her right ranula was diminished by the treatment, but her left ranula was getting big.

Upper: From Left, Before aspiration, Just after aspiration, 3 days, 2 weeks after aspiration
Lower:
From Left, 3 weeks, 8 weeks, 9 weeks, 10 weeks, 4 months after aspiration

Additional aspiration therapy. 30 days after OK-432 injection, she came to me again. Her right ranula was disappeared but her left ranula was markedly swollen. I wanted to inject OK-432 into her left ranula, but this time only aspiration was done because of her school schedule. 3 days after aspiration, ranula became bigger. And 3 weeks after aspiration, the swelling was going down. After 8 weeks, the swelling continued. But, after 9 weeks, the swelling was spontaneously reduced. At the period of 10 weeks after aspiration, the swelling was completely disappeared.

After that, there was no recurrence for one year.

Important points for this patient are
@1, Ranula was bilateral.
@2. She had 3 surgeries with general anesthesia but recurred and changed to plunging ranula.
@3. She had 3 OK-432 therapy but failed and fistula was formed by the last injection.
@4. Why and how her left ranula was cured,
About 1, I have experienced 4 cases of bilateral ranula. They were all young. Ranula is a saliva leakage from sublingual gland. I guess constitution of lability of salivary gland might be thought .
About 2, Removal of ranula does not promise cure. Ranula is a leakage of saliva, so if the leakage did not stop, it will recur after complete removal. It is sometimes experiences that oral ranula turned to be plunging ranula. Plunging ranula 1, 10 and combined ranula 3 were so. After operation, oral floor became scared, saliva goes to downward. Regrettably, still now, some book wrote that complete removal was necessary for prevention of recurrence. The aim of treatment of ranula is to stop leakage from sublingual gland. If you have a operation, removal of sublingual gland is the best. She had removal of sublingual gland but it was done from neck. I think it was not perfect removal.
About 3, the efficacy was different if they think main treatment is surgery or OK-432. And, if there is weak lesion of skin or mucous membrane by 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 after OK-432 therapy. OK-432 therapy must be done before surgery.
About 4, The size of ranula is determined by the balance between increase factor (saliva leakage) and decrease factors (compression, absorption), If the balance go to decrease, spontaneous regression occurs.

Please Click here to go to English Page with frame (If you can't see frame, click it)