A congenital ranula is a rare cystic malformation seen in the oral cavity. This pseudocyst is normally located in the sublingual space between the mylohyoid muscle and the lingual mucosa. A 24-year-old woman, gravida 3, para 2, at 29 weeks' gestation was referred to our institution because of polihydramnios and large oral mass.Rânula congênita uma rara malformação cística visualizada na cavidade oral. É um pseudocisto habitualmente localizado no espaço sublingual entre o músculo milo-hioideo e a mucosa da língua. Relata-se um caso de gestante de 24 anos, G3P2, com idade gestacional de 29 semanas, encaminhada por conta de polidrâmnio e grande massa de cavidade oral de natureza cística.Universidade Federal do Maranhão Serviço de Ginecologia e ObstetríciaUniversidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Departamento de ObstetríciaUNIFESP, EPM, Depto. de ObstetríciaSciEL

Araujo Júnior, Edward

Martins, Marília Da Glória

Moron, Antonio Fernandes

Nardozza, Luciano Marcondes Machado

Rios, Livia Teresa Moreira

Radiologia Brasileira

Repositório Institucional UNIFESP

300Rios LTM et al. Congenital ranula: antenatal sonographic diagnosisRadiol Bras. 2012 Set/Out;45(5):300–301Congenital ranula: antenatal sonographic diagnosis*Rânula congênita: diagnóstico ultrassonográfico antenatalLivia Teresa Moreira Rios1, Edward Araujo Júnior2, Luciano Marcondes Machado Nardozza3,Antonio Fernandes Moron4, Marília da Glória Martins5A congenital ranula is a rare cystic malformation seen in the oral cavity. This pseudocyst is normally located in thesublingual space between the mylohyoid muscle and the lingual mucosa. A 24-year-old woman, gravida 3, para 2, at29 weeks’ gestation was referred to our institution because of polihydramnios and large oral mass.Keywords: Prenatal diagnosis; Ultrasound; Oral tumor; Ranula.Rânula congênita uma rara malformação cística visualizada na cavidade oral. É um pseudocisto habitualmente loca-lizado no espaço sublingual entre o músculo milo-hioideo e a mucosa da língua. Relata-se um caso de gestante de 24anos, G3P2, com idade gestacional de 29 semanas, encaminhada por conta de polidrâmnio e grande massa de ca-vidade oral de natureza cística.Unitermos: Diagnóstico pré-natal; Ultrassom; Tumor oral; Rânula.AbstractResumo* Study developed at the Service of Gynecology and Obstet-rics of Hospital Universitário da Universidade Federal do Maranhão(UFMA), São Luís, MA, and at Department of Obstetrics, EscolaPaulista de Medicina – Universidade Federal de São Paulo (EPM-Unifesp), São Paulo, SP, Brazil.1. Master, MD, Unit of Ultrasonography, Service of Gynecol-ogy and Obstetrics, Universidade Federal do Maranhão (UFMA),São Luís, MA, Brazil.2. PhD, Associate Professor, Division of Fetal Medicine, De-partment of Obstetrics, Escola Paulista de Medicina –Universidade Federal de São Paulo (EPM-Unifesp), São Paulo,SP, Brazil.3. Private Docent, Associate Professor, Division of Fetal Medi-cine, Division of Obstetrics, Escola Paulista de Medicina –Universidade Federal de São Paulo (EPM-Unifesp), São Paulo,SP, Brazil.4. Private Docent, Chair of the Department of Obstetrics, Es-cola Paulista de Medicina – Universidade Federal de São Paulo(EPM-Unifesp), São Paulo, SP, Brazil.5. PhD, Associate Professor, Service of Gynecology and Ob-stetrics, Universidade Federal do Maranhão (UFMA), São Luís,MA, Brazil.Mailing Address: Dr. Edward Araujo Júnior. Rua Carlos Weber,956, ap. 113, Visage, Vila Leopoldina. São Paulo, SP, Brazil,05303-000. E-mail: araujojred@terra.com.brReceived March 17, 2012. Accepted after revision July 20,2012.Rios LTM, Araujo Júnior E, Nardozza LMM, Moron AF, Martins MG. Congenital ranula: antenatal sonographic diagnosis. Radiol Bras.2012 Set/Out;45(5):300–301.0100-3984 © Colégio Brasileiro de Radiologia e Diagnóstico por ImagemCASE REPORTtable proposed by Moore & Cayle(4)). At the30th gestational week, preterm prematurerupture of ovular membranes was diag-nosed and the woman entered prematurelabor. Cesarean section was performed, andmacroscopic examination confirmed theprevious findings. Decompression wasperformed by means of percutaneous aspi-ration of the cystic collection. The neonatedied some hours after birth because of res-piratory complications.DISCUSSIONIn the last years, ultrasonography hasbeen widely utilized by all obstetrics refer-ence centers. Amongst the recent advancesin imaging diagnosis, 3D ultrasonography(3DUS) is utilized with amplitude Dopplerto assess the fetal brain vascularization(5) orthe fetal limbs volume(6).Ranula is most commonly found in chil-dren and young adults, and rarely occurs inneonates. This entity may be classified ac-cording its location, as follows: simpleranula – located on the floor of the mouth;cervical ranula – located in the paracervicalregion; and plunging ranula – located nearto the upper airways, resulting from ruptureof a simple ranula. Few cases of antenataldetection of ranulas have been reported inthe literature(2). Solid and cystic exophyticmasses should be considered in the differ-in the sublingual space between the mylo-hyoid muscle and the lingual mucosa, withestimated prevalence of 0.74%(3). Fewcases of prenatal diagnosis have been re-ported in the literature.The authors report the case of a con-genital ranula, antenatally diagnosed by ul-trasonography, emphasizing possible dif-ferential diagnoses.CASE REPORTA 24-year-old, G3P2 woman, with ges-tational age around 29 weeks, was referredto the Unit of Ultrasonography, Service ofGynecology and Obstetrics, UniversidadeFederal do Maranhão (UFMA), because ofpolihydramnios and a large oral cavitymass of cystic nature. Both personal andfamily history with no relevant data. Ob-stetric ultrasonography was performed andrevealed the presence of a large, anechoic,homogeneous cystic mass measuring 5.0cm in diameter, with thin and smooth 2.8cm thick walls (Figures 1 and 2). Vascular-ization was not observed at color Dopplerultrasonography. Fetal screening did notreveal any other associated malformation.Increased amniotic fluid volume wasobserved. The largest pocket measured 112mm, and the amniotic fluid index (AFI)was 317 mm (normal between 92 and 231mm for gestational age, according to theINTRODUCTIONCongenital ranula is a rare tumor lo-cated on the mouth floor which raises thetongue. It may be caused either by a mu-cus extravasation cyst secondary to ob-struction and rupture of sublingual or mi-nor salivary glands, or, less commonly, toa mucus retention cyst originating fromdilatation of an obstructed submandibulargland duct, and therefore surrounded byepithelium(1,2).Congenital mucus extravasation cyst ormucoceles is a pseudocyst usually located301Rios LTM et al. Congenital ranula: antenatal sonographic diagnosisRadiol Bras. 2012 Set/Out;45(5):300–301ential diagnosis, as well as lymphatic mal-formations, epignatus (oropharyngeal ter-atoma) and other cystic lesions of themouth(2,7). Lymphatic malformations (vas-cular hamartomas and lymphangiomas) aresolid-cystic lesions with indistinct and ir-regular margins, which are observed fromthe birth and continue to grow with thedevelopment of the patient(2,7,8). Oropha-ryngeal teratoma or epignatus is an uncom-mon, solid tumor that is seen as hypo- andhyperechogenic areas, affecting between1:35000 and 1:200000 living neonates,with high morbidity and mortalityrates(2,9,10). Cystic lesions considered in thedifferential diagnosis for congenital ranulainclude gingival and palatal cysts, whoseresolution occurs spontaneously(2) and,more rarely, thyroglossal duct cysts typi-cally located on the buccal floor, duplica-tion cysts and cysts with heterotopic gas-tric mucosa(7). In such cases, magnetic reso-nance imaging (MRI) could be useful in thedifferential diagnosis. Tamaru et al.(11) havedescribed a case of ranula diagnosed at the36th gestational week, where MRI identi-fied a small lesion in the midline of themouth, in the sublingual space, below themylohyoid muscle, where a T2-weightedsequence clearly defined the presence of ahomogeneous mass. Other described pre-natal diagnostic method is 3DUS, whichcan play a role as adjuvant to 2D ultra-sonography, allowing a spatial evaluationof the relation between the mass and theoral cavity of the fetus(12).In the present case, the diagnosis of thecystic lesion was facilitated by the findingsof homogeneity, thin and regular walls atultrasonography, and avascular mass atcolor Doppler, besides the aspirated mu-cous content. A correct antenatal diagnosisbecomes extremely relevant because gen-erally such neonates present varied degreesof airways obstruction, requiring the pres-ence of a multidisciplinary team includingobstetricians, neonatologists and head &neck surgeons at the moment of the birth.Such a multidisciplinary team is requiredto avoid respiratory failure, and many timesit is necessary to perform extrauterine in-trapartum treatment – a procedure carriedout during the Cesarean section, with pres-ervation of the fetal-placental circulation,which allows a safe handling of the concep-tus’ airways, reducing the risk of airwaysobstruction.In summary, the authors describe a caseof antenatal diagnosis of ranula. The cor-rect diagnosis is essential to allow a prena-tal follow-up in a reference center, besidesthe planning of the delivery with a multi-disciplinary team.REFERENCES1. Galloway RH, Gross PD, Thompson SH, et al.Pathogenesis and treatment of ranula: report ofthree cases. J Oral Maxillofac Surg. 1989;47:299–302.2. Onderoglu L, Saygan-Karamürsel B, Deren O, etal. Prenatal diagnosis of ranula at 21 weeks ofgestation. Ultrasound Obstet Gynecol. 2003;22:399–401.3. Jorgenson RJ, Shapiro SD, Salinas CF, et al. In-traoral findings and anomalies and neonates. Pe-diatrics. 1982;69:577–82.4. Moore TR, Cayle JE. The amniotic fluid index innormal human pregnancy. Am J Obstet Gynecol.1990;162:1168–73.5. Moron AF, Milani HJ, Barreto EQ, et al. Análiseda reprodutibilidade do Doppler de amplitudetridimensional na avaliação da circulação do cé-rebro fetal. Radiol Bras. 2010;43:369–74.6. Cavalcante RO, Araujo Júnior E, Nardozza LM,et al. Reprodutibilidade do volume de membrosfetais pela ultrassonografia tridimensional utili-zando o método XI VOCAL. Radiol Bras. 2010;43:219–23.7. Fernandez Moya JM, Cifuentes Sulzberger S, DíazRecaséns J, et al. Antenatal diagnosis and man-agement of a ranula. Ultrasound Obstet Gynecol.1998;11:147–8.8. Rousseau T, Couvreur S, Senet-Lacombe E, et al.Prenatal diagnosis of enteric duplication cyst ofthe tongue. Prenat Diagn. 2004;24:98–100.9. Martinelli P, Paladini D, Nicotra A, et al. In uterodiagnosis of oropharyngeal teratoma: a case re-port. Eur J Obstet Gynecol Reprod Biol. 1990;35:291–4.10. Levine AB, Alvarez M, Wedgwood J, et al. Con-temporary management of a potentially lethalfetal anomaly: a successful perinatal approach toepignathus. Obstet Gynecol. 1990;76:962–6.11. Tamaru S, Kikuchi A, Ono K, et al. Prenatal ul-trasound and magnetic resonance imaging depic-tion of a small sublingual ranula. J Clin Ultra-sound. 2010;38:147–50.12. Pires P, Pereira M, Machado L, et al. Prenatal di-agnosis of a ranula with 2- and 3-dimensionalsonography and sonographically guided aspira-tion. J Ultrasound Med. 2006;25:1499–502.Figure 1. Lateral view of fetal face demonstrating a large anechoic, homoge-neous collection with thin and regular walls, impairing the fetal deglutition.Figure 2. Coronal section of fetal face revealing normality of the nose and upperlip, and highlighting the increased diameter of the cystic mass.

Congenital ranula: antenatal sonographic diagnosis

Rânula congênita uma rara malformação cística visualizada na cavidade oral. É um pseudocisto habitualmente localizado no espaço sublingual entre o músculo milo-hioideo e a mucosa da língua. Relata-se um caso de gestante de 24 anos, G3P2, com idade gestacional de 29 semanas, encaminhada por conta de polidrâmnio e grande massa de cavidade oral de natureza cística.</jats:p

Congenital ranula: antenatal sonographic diagnosis

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