Plunging ranulas revised: A CT study with emphasis on a defect of the mylohyoid muscle as the primary route of lesion propagation

The purpose of this study was to clarify the pathogenesis of plunging ranulas in regard of the pathway of lesion propagation using CT scans. We retrospectively reviewed CT scans of 41 patients with plunging ranula. We divided plunging ranulas into two types: type 1 was defined as those directly passing through a defect of the mylohyoid muscle with the presence (type 1A) or absence (type 1B) of the tail sign and type 2 as those through the traditional posterior route along the free edge of the mylohyoid muscle. Images were also analyzed for the extent of the lesion in respect to the spaces involved. As for type 1 lesions, we recorded the location of the defect of the mylohyoid muscle and the position of the sublingual gland in relation to the defect. CT scans demonstrated type 1 lesion in 36 (88%), including type 1A in 14 and type 1B in 22, and type 2 lesion in 5 (12%). Irrespective of the type, the submandibular space was seen to be involved in all cases either alone or in combination with one or more adjacent spaces. Of the 36 patients with type 1 lesions, the anterior one-third was the most common location of the defect of the mylohyoid muscle, seen in 22 patients. The sublingual gland partially herniated in 30 patients. Our results suggest that the majority of plunging ranulas take an anterior shortcut through a defect of the mylohyoid muscle