Hydrodissection for complete removal of a ranula.

Abstract

Hydrodissection has been used in various surgical fields to facilitate excision in both routine and difficult cases. This procedure involves the injection under pressure of saline and lidocaine with 1:100,000 epinephrine into the dissection plane. Removing a ranula without rupturing it can be a tedious and time-consuming process. Therefore, we used hydrodissection to assist us in performing these procedures. To review our experience with the treatment of ranulas, we performed a retrospective study of 38 patients who had undergone hydrodissection for ranula removal between January 1996 and December 2002 at our academic tertiary, care hospital. Compared with other removal techniques, we found that hydrodissection was associated with less bleeding, fewer incidents of neural and soft-tissue damage, and a lower recurrence rate. In addition to reporting our study results, we also describe our hydrodissection technique, which is relatively simple, effective, and convenient for otolaryngologists.

Introduction

Ranulas typically arise superior to the mylohyoid muscle. They are caused by obstruction of the sublingual ducts, which can result in the retention of saliva and the formation of the cyst within the substance of the sublingual gland. (1) The diagnosis can be easily made because the lesion is readily apparent on physical examination (figure 1). A suprahyoid or plunging ranula is large and can manifest as a neck mass that extends through the mylohyoid.

[FIGURE 1 OMITTED]

Several different methods of treatment have been used for the removal of ranulas. They include cold-knife excision, cryosurgery, marsupialization, laser excision, and intralesional injection of OK-432. (2) In some cases, only the ranula itself is removed; in other cases, both the lesion and the sublingual gland are removed via an intraoral approach. The most common complication of surgery in the latter case is a failure to excise the sublingual gland completely, which results in the presence of residual gland tissue and increases the risk of recurrence. Revision surgery is significantly more difficult than primary surgery, and it is associated with a higher risk of complications. Meticulous dissection and complete removal of the lesion during the first surgery are therefore important.

Hydrodissection has been used to facilitate dissection in difficult cases in various surgical fields. (3,4) During otolaryngologic surgical procedures, especially septoplasty, we have injected a solution of 1% lidocaine with epinephrine into the submucoperichondrial space for bydrodissection? In this article, we describe our study of ranula removal by "hydraulic dissection."

Patients and methods

Between January 1996 and December 2002, 38 patients--20 males and 18 females, aged 3 to 61 years (mean: 22.5)--underwent removal of a ranula by hydrodissection in the Department of Otolaryngology-Head and Neck Surgery at Wonkwang University Hospital. Nine of these patients (23.7%) were being treated for recurrences following management (e.g., simple aspiration, excision, marsupialization, etc.) at other hospitals.

All procedures were performed in the operating room. Patients aged 16 years and older were administered local anesthesia with sedation, and younger patients were administered general anesthesia. After adequate infiltration of the submucosal area of the ranula with normal saline and lidocaine with 1:100,000 epinephrine, we extirpated the ranula carefully. The hemostatic effect of the epinephrine minimized bleeding, which helped achieve a precise and rapid resection and minimized the risk of recurrence and neural and soft-tissue injury.

Our injection technique involves beveling the needle toward the ranula and meticulously injecting the solution under pressure into the plane. A small amount (< 10 ml) of the solution can be injected with a dental syringe and a 30-gauge (25-mm) needle along the margin of the ranula (figure 2). A multiple-injection technique can be used around the mass, but it is important to limit the depth of the needle to avoid inadvertently rupturing the ranula capsule. Once injected, the fluid dissects along the ranula and creates a bloodless and safe dissection plane within a few minutes.

[FIGURE 2 OMITTED]

We dissected along the infiltration plane to the ranula while managing to avoid rupturing it and preventing the loss of too much soft tissue. Surgical dissection can be performed with either a scalpel, Metzenbaum scissors, or electrical needle device. Care must be taken to avoid injury to the lingual nerve and submandibular duct. Rarely is bleeding encountered, but when it is, it can be controlled by meticulous bipolar cautery. Following removal of the cyst, we performed a primary closure with Vicryl 4-0 suture. A Penrose drain was not placed in the operating wound, and stitches were not removed.

Results

The mean operating time from the moment of hydrodissection to wound closure was approximately 1 hour. All of the surgically removed specimens were submitted tot microscopic examination. Histologic examination revealed that these lesions were pseudocysts that were lined with nonepithelial layers, filled with mucus, and limited by granulation tissue. The postoperative course in all patients was uneventful. Patients were able to resume an oral diet either immediately or no later than the following morning. The duration of postoperative hospitalization ranged from 2 to 5 days (mean: 4). The degree of postoperative discomfort and the incidence of complications were minimal. The most common complication was a mild limitation of tongue movement secondary to local anesthesia and swelling of the tongue; these complications resolved spontaneously.

Follow-up examination 4 weeks postoperatively revealed that the mucosa of the oral cavity in all patients had healed completely without significant scar formation. The duration of follow-up ranged from 5 to 82 months (mean: 36.5); three patients were lost to follow-up. No recurrences or infections were reported, and all patients were satisfied with the result.

Discussion

Several controversies have attended the various methods of treating ranulas, and each method has its own advantages and disadvantages. Aspiration, incision and drainage, and marsupialization are associated with a higher risk of recurrence. Cryosurgery is still unpredictable because of the unreliability of the frozen state. Intracystic injection of OK-432 (for lymphangiomas as well as ranulas) is contraindicated in patients who are allergic to penicillin; this procedure also causes several adverse effects, including fever and local pain. (2)

Regardless of the procedure that is used, the surgeon should endeavor to avoid injury to the lingual nerve and Wharton's duct and should take steps to minimize the risk of recurrence. Moreover, when excision is performed with a cold knife or a laser, the surgeon must take great care to avoid rupturing the ranula because the cystic wall is thin and friable.

Excision of both the ranula and the sublingual gland via an intraoral approach has been recommended, but we believe that complete extirpation of the sublingual gland is unnecessary. The most common pitfall during excision is a failure to remove the sublingual gland completely; such a failure increases the risk of recurrence.

Removal of a ranula via hydrodissection preserves the surrounding normal tissue and the dissection plane. During the past 7 years, we have found that this technique is a safe and simple means of removing a ranula. Compared with other techniques, hydrodissection is associated with less bleeding, fewer incidents of neural and soft-tissue damage, and a much shorter operating time.

References

(1.) Yoshimura Y, Obara S, Kondoh T, Naitoh S, A comparison of three methods used for treatment of ranula. J Oral Maxillofac Surg 1995;53:280-2; discussion 283.

(2.) Ikarashi T. Inamura K, Kimma Y. Cystic lymphaugioma and pluuging ranula treated by OK-432 therapy: A report of two cases. Acta Otolaryngol Suppl 1994;511:196-9,

(3.) Harvey JC, Erdman CB. Beattie EJ. Early experience with videothoracoscopic hydrodissection pleurectomy in the treatment of malignant pleural effusion. J Surg Oncol 1995;59:243-5.

(4.) Solomon MP. Tumescent technique as an adjunct to breast implant removal and capsulectomy. Ann Plast Surg 2000;44:495-7.

(5.) Tardy ME, Surgery of the nasal septum and airway. In: Tardy ME. Rhinoplasty: The Art and the Science, Philadelphia: W.B. Saunders, 1997:572-647.

From the Department of Otolaryngology--Head and Neck Surgery, Wonkwang University Hospital, Wonkwang University School of Medicine, Iksan, Jeonbuk, Republic of Korea.

Reprint requests: Tae-Wook Choi, MD, Department of Otolaryngology-Head and Neck Surgery. Wonkwang University Hospital. Wonkwang University School of Medicine, 344-2 Sinyong-dong, Iksan. Jeonbuk 570-711. Republic of Korea. Phone: [phone]; fax: [phone]; e-mail: [e-mail]

The preparation of this article was supported by Wonkwang University in 2003.