COMPARISION OF EXTRAMUCOSAL ENUCLEATION AND SUBMUCOSAL EXCISION TECHNIQUE FOR THE TREATMENT OF ORAL MUCOCELE AT BIRAT MEDICAL COLLEGE & TEACHING HOSPITAL , MORANG , NEPAL Affiliation

Citation Shah RK, Sharma VA, Atreya A, Gyawali S. Comparision of extramucosal enucleation and submucosal excision technique for the treatment of oral mucocele at Birat Medical College & Teaching Hospital, Morang, Nepal. BJHS 2017;2 (2)3 : 215-218 * Corresponding Author Dr. Rajeev Kumar Shah Lecturer Department of Otolaryngology Birat Medical College & Teaching Hospital, Morang, Nepal Email: shahrajeev2001@gmail.com ABSTRACT


Objec ves
The present study is aimed to observe the prevalence of mucocele in Eastern Region of Nepal and to compare the results of extramucosal enuclea on and submucosal excision as the treatment of mucocele.

Methodology
This prospec ve study was conducted on pa ents diagnosed with mucocele in Birat Medical College Teaching Hospital; a ter ary centre in Eastern Nepal during the period between June 2014 to April 2017.Out of total 37 cases two groups were divided based upon size of mucocele.Pa ents underwent extramucosal enuclea on in cases where the size of mucocele was less than 1 cm and submucosal excision was done in pa ents whose size of the mucocele exceeded 1 cm.The data was entered and analyzed using Sta s cal Package for the Social Sciences (SPSS) vs 21.Different parameters like wound infec on, scar forma on, recurrence, healing me, follow up were compared for both the methods.

Result
The mean age of the pa ent in extramucosal enuclea on was 9.90±2.807while in submucosal excision was 11.22±3.068years.The most common loca on for mucocele in both the groups was the lower lip; who underwent either extramucosal enuclea on (90%) or submucosal excision (70.4%).Recurrence was not observed in submucosal excision whereas one pa ent with extramucosal enuclea on had recurrence.

Conclusion
Submucosal excision is more effacious for the treatment of Mucocele in comparison to extramucosal enuclea on as it usually healed within a week with fewer incidences of wound infec on and without any recurrence.

INTRODUCTION
Mucocele is a common benign, cys c lesion of the oral mucosa due to mucous accumula on of the minor salivary glands.It is generally asymptoma c, single, painless, 1 smooth, so , spherical translucent and fluctuant nodule.It is most frequently seen in young and adolescent age groups [2][3][4] and rarely among children under one year of age.Although minor salivary glands are found in most parts of the oral cavity except the gingiva, mucocele occur most commonly in the lower lip, probably due to the higher incidence of 5 mechanical trauma in this region.
Mucoceles are of two types based upon their microscopic characteris cs: Extravasa on and Reten on type.Reten on mucocele have epithelial ssue where as extravasa on 6 mucocele is covered by granula on ssue.Extravasa on mucocele is because of trauma to the salivary gland duct with consequent spillage of the secre on into the so ssues around the gland whereas reten on type is due to a decrease or absence of glandular secre on produced by blockage of the salivary gland ducts.
Mucoceles of the minor salivary glands are always superficial and rarely larger than 1.5 cm.However, ranulas are larger and arise from deeper areas such as the floor of the mouth.Ranula causes discomfort, interference with speech, 7 mas ca on, and swallowing.
Clinically, mucocele is a dome shaped cys c swelling, some mes associated with a bluish hue.This bluish discoloura on is due to vascular conges on, which is due to cyanosis of ssue above and collec on of fluid below.
Micromarsupaliza on, electrocautery, laser, gamma linolenic acid, cryosurgery, infiltra on of silver nitrate, infiltra on of nickel gluconate, mercurius heel and simple surgical excision are some of the techniques used for the 1,4,6,8-16 treatment of mucoceles.
In cases where the lesion is not problema c and the pa ents refuses to get operated, 17 close monitoring and watchful wai ng can be done.However, surgical excision is portrayed by most of the surgeons.The present study is conducted to evaluate the spectrum of oral mucocele in a ter ary centre of eastern region of Nepal and to compare two surgical methods of mucocele treatment: submucosal excision and extramucosal enuclea on.

METHODOLOGY
This prospec ve study was conducted during June 2014 to April 2017 on pa ents diagnosed with mucocele in the department of ENT, Birat Medical College Teaching Hospital, Tankisinuwari, Morang.A er the proper clinical diagnosis of mucocele the subjects were divided into 2 groups who were planned for submucosal excision or extramucosal enuclea on as a mode of surgical treatment.Informed wri en consent was taken from the pa ent who wished to par cipate in the study.The younger pa ents under the age of 20 years were taken into considera on in the present study because mucocele is more common in young and adolescent popula on.Extramucosal enuclea on was done in pa ents where the size of mucocele was less than 1 cm and submucosal excision was done in mucocele with a size exceeding 1 cm.In extramucosal excision the mucocele was excised and flushed with its a achment to the lip a er applint gentle trac on on the mucocele using Babcock's forceps.Excision was done with no.11 scalpel apply in the raw bleeding base was cauterized gently with bipolar cautery.No further cautery was required for the base a er laser excision.
In submucosal enuclea on approach infiltra on was done with insulin syringe to create hydro-dissec on between lip mucosa and the mucocele.Incision was made on the lip mucosa and mucosal flaps were fashioned to expose the underlying grey mucocele.The mucocele was carefully dissected free with iris scissors and excised.The mucosal flaps were then sutured with 4-0 Vicryl.
The demographic parameters and other associated medical history were entered into the proforma which included loca on of the lesion, associated symptoms and other relevant informa on.Different parameters like wound infec on, scar forma on, recurrence, healing me, follow up were compared for both the methods.The data was entered and analyzed using Sta s cal Package for the Social Sciences (SPSS) vs 21 and presented in appropriate tables.The variables like wound infec on, scar forma on, recurrence, healing me, follow up were compared for both the methods.The study was approved by ins tu onal ethics commi ee of Birat Medical College Teaching Hospital.

RESULTS
During the study period there were 37 pa ents admi ed in the hospital with a history of mucocele of which 20 were females and 17 males.The mean age of the study par cipants was 10.86±3.020 of them female was 10.75±3.110and male was 11±3.00.The size of the mucocele was between 1cm and 1.5 cm in 51.4% cases and was confined to lower lip in 75.7% cases [Table 1].Submucosal excision was chosen as a mode of treatment in 27% of cases whereas in 73% cases mucocele was removed by extramucosal enuclea on.Recurrence and scar forma on was rare which was seen in only 2.7% of cases [Table 2].Recurrence was noted a er extramucosal enuclea on of mucocele during followup at the end of 4 weeks post-surgery.In this par cular case repeat surgery was done a er 8 weeks.
When the two methods were compared as shown in [Table 3] it was observed that 70% of females underwent extramucosal enuclea on whereas not much difference was observed based upon gender in submucosal excision.Percentage of females undergoing submucosal excision and extramucosal enuclea on was 48.1% and 70% respec vely.The mean age of the pa ents in Extramucosal enuclea on was 9.90±2.807while in submucosal excision was 11.22±3.068years.Recurrence and mucocele forma on a er treatment of mucocele was rare.In our study there was a single case where scar had formed a er submucosal excision and a case of extramucosal enuclea on where recurrence had occurred.It was observed that pa ent follow up at the end of first week was remarkably similar for both the methods; 77.8% for submucosal excision and 80% for extramucosal enuclea on.In the contrary, 70.4% and 70% cases of submucosal excision and extramucosal enuclea on respec vely didn't show up for follow-up a er 4 weeks.Wound infec on as a complica on was rarer for submucosal excision (3.7%) however it was frequently seen in extramucosal enuclea on (40%).There was a contrast when healing me was considered for both the methods.Pa ents who underwent submucosal excision had a quick healing of the wound within a week (74.1%)whereas it took more than a week in 80% of pa ents who underwent extramucosal enuclea on.Sta s cally, no significant observa on was made when Pearson chi square test was applied to compare both the methods.

DISCUSSION
Mucocele is a painless swelling confined mostly to the lower lip.Even though mucocele may not cause physical discomfort pa ents may feel embarrassed with decreased 18 social acceptance and self-esteem.
The incidence of mucocele is affected by geography, sociocultural prac ce and tradi on.The authors believe that people with low socioeconomic class tend to neglect oral hygiene increasing the likelihood of oral lesions.
Mucocele is a painless oral lesion more prevalent in young Mucocele a er excision have higher chance of recurrence, however, in this study there was a single case of recurrence in the pa ent who had undergone extramucosal enuclea on.
The recurrence was treated with revision surgery.
There was one pa ent who developed wound infec on.He was found to have poor oral hygiene with the food par cles lodge in inside the wound.the infected wound was cleaned with saline water and treated an bio c a er resuturing.The wound developed scar later on.
Shah RK et al