Plunging ranula (15) (Big ranula, Repeat ruptures after OK-432 injection)

Left: Before treatment. Right: After treatment

8 years old girl. She had treatment for two years, but her ranula became bigger and bigger.
Two years ago, she had right oral ranula like small black clam shell. She had a surgery by a neighboring dentist. 4 months later, her right jaw became to be swollen. She went to an Hospital. She had OK-432 injection from oral under general anesthesia. The swelling was disappeared within 1 week. This is too short duration for the effect of OK-432. Appearance of the effect by OK-432 needs at least 4 weeks. After 4 months, her right jaw was more swollen. So, she had the same therapy at the same hospital. She had the same course. She was recommended to have surgery. Her parents did not want to have surgery, so went another hospital and got 3rd OK-432 therapy. This time also, she had the same course. Namely, her swelling of right jaw was disappeared within 1 week after OK-432 therapy. The last night for disappearance of her right jaw swelling, she complained viscous mucous flow in her mouth and her mother saw it. This means rapture of ranula to oral cavity. The patient who had surgery before sometimes takes this course. Injured mucous membrane can not endure the pressure after OK-432 therapy.

Upper: From Left, Before aspiration, Cyst fluid, After aspiration, The next day after aspiration
Lower:
From Left,1 week, 2 weeks, 3 weeks after aspiration

This is her external appearance when she first came to my clinic. She had the biggest ranula I had experienced. Because she came on Saturday, only aspiration was performed. I punctured her left jaw and aspirate 100 ml of mucous fluid. After aspiration, her appearance became normal, but on the next day you can see swelling at her left jaw. After that, swelling was gradually increased. The lower right is the swelling 3 weeks after aspiration.


Upper: From Left, Before treatment, Cyst fluid and injected OK-432, Just after treatment
Lower:
From Left, The next day, 2 weeks, 4 weeks, 6 weeks after treatment

The first injection of OK-432. 3 weeks after first aspiration, she came to me for having OK-432 therapy. This was the first day of her summer holidays. Aspiration of 50 ml cyst fluid was performed then 1.5 KEG of OK-432 in 4 ml saline was injected. Lower left is the next day after OK-432 injection. Her left jaw was markedly swollen and reddened . From 2 weeks to 6 weeks after treatment, the swelling was gradually reduced. But, at the period of 6 weeks after treatment, the swelling began to regrow.

Upper: From Left, Before treatment, Injected OK-432, The next day after treatment
Lower:
From Left, 3 days, 4 weeks, 6 weeks, 8 weeks after treatment

The second injection of OK-432. So, the second injection was performed 7 weeks after the first injection. This time, ranula became to be a combined type. So, I inject 1 KE of OK-432 with highly concentrated OK-432 injection without aspiration method. Upper right is the next day after treatment. Response was very good. But, her oral floor was raptured 3 days after OK-432 injection. This might be the same course of former OK-432 therapy by other physicians. Rapture means the same effect of marspialization operation. The swelling was disappeared for a while, but recurred gradually.

Upper: From Left, Before, 2 days after, 2 weeks after treatment
Lower:
From Left, 4 weeks, 2 months, 3 months, 4 months after treatment

The third injection of OK-432.The third injection was performed 9 weeks after the second injection. But, she had the same course as that of the second OK-432 injection. This time, we decided to wait as much as possible. 3 to 4 months after treatment, you can see the swelling was hanging down in her neck. This is the course resembles to that of plunging ranula 14.


Upper: Left: Before aspiration, Middle: The next day after aspiration, Right: 1 week after aspiration
Lower:
from Left, 2 weeks, 4 weeks, 6 weeks, 10 weeks after aspiration

The first aspiration therapy after OK-432 injection. I have experienced that left ranula of plunging ranula 14 of this home page was cured by only aspiration after OK-432 injection. So, this time, only aspiration was performed. After aspiration, ranula sometimes became small and sometimes became big. But, finally, ranula became relatively big 10 weeks after aspiration.

Upper: From Left, Before and just after aspiration, The next day, 1 week after aspiration
Lower:
From Left, 2 weeks, 4 weeks, 6 weeks, 7 weeks after aspiration

The second aspiration therapy after OK-432 injection. So, I thought OK-432 must be injected again. But, because of post treatment swelling, her parents wanted to be treated during summer holidays. 11 weeks after the first aspiration, the second aspiration was performed. From the next day to one week after the second aspiration, the swelling was obvious. But, after 2 weeks, the swelling was spontaneously decreased. We were planning to treat at the beginning of summer holidays ( 4 weeks after the second injection). This plan was postponed. The swelling was completely disappeared 7 weeks after the second aspiration.

The third aspiration therapy after OK-432 injection. So, I was thinking her ranula was disappeared by the third aspiration therapy. But, her ranula began to regrowth14 weeks after the third aspiration.Of course I thought OK-432 must be injected again. But, because of post treatment swelling, her parents wanted to be treated during winter holidays. 21 weeks after the second aspiration, the third aspiration was performed. After the third aspiration, her ranula began to regrowth immediately.

The fourth injection of OK-432.The fourth OK-432 injection was performed 8 weeks after the third iaspiration therapy. Her ranula was swollen and reddened on the next day after treatment. The inctreased swelling lasted for one week. Then it began to shrink. 6 weeks after OK-432 injection, her submandibular swelling was diminished.
By 6 months after last OK-432 treatment, there is no recurrence,But, she had the same course as that of the second nt, you can see the swelling was hanging down in her neck. This is the course resembles to that of plunging ranula 14.


This is one year after the 4th OK-432 therapy. There is no recurrence.

Finally, it took one and a half year to cure from the beginning of my treatment. But, this very big ranula was completely disappeared without having any surgery. She came to my clinic total 8 times. She is living 300 miles away from my clinic. Only one visit , the first OK-432 injection, was 2 days treatment, stayed hotel near my clinic. Another 7 visit was one day trip on Saturday. She could spend usual school life during treatment.

Important points for this patient are
 1, She had a surgery for small oral ranula but recurred as big plunging ranula.
 2. She had three OK-432 therapy by other physician. But, failed and became more big ranula.
 3. Why and how her left ranula was cured,
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 and combined ranula 3 of this home page 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.
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.

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