Differentiating Lymphatic Malformations from Ranulas in Pediatric Neck Masses

The 16-year-old presented with right submandibular swelling that was soft and painless.

CT scan showed a cystic mass heading up underneath the mandible that abuts the submandibular gland on the right side.

It can be really hard to differentiate a giant ranula from a lymphatic malformation.

The lab tends to have trouble running thick fluid from aspirated neck masses.

Lymphatic malformations near glandular tissue can have leaching of saliva into them, resulting in a false positive amylase test.

Ultrasound suggested the mass was a lymphatic malformation.

Removal of all sublingual glandular tissue made Dr. Van Alman confident the mass was a lymphatic malformation rather than a ranula.

From a ranula perspective, removal of the sublingual gland has been the best practice.

When a ranula has a cervical component, you can aspirate that, and as long as you remove the sublingual gland, it should go away.

Micromarsupialization is a new technique to treat ranula: if you can identify an intraoral component, you throw silk sutures through the cyst, let it sit for 30 days to develop a fistula, then cut the sutures out and it will spontaneously drain into the mouth.

Gene panels now guide medical therapy for lymphatic malformations, particularly PIK3CA mutations, which suggest that alpelisib (a PI3K alpha inhibitor) can be useful.

For congenital developmental neck masses, you have to not just excise the mass but deal with the embryological component and etiology to prevent recurrence.