eMedicine Specialties > Dermatology > Diseases of the Oral Mucosa

Mucocele and Ranula: Differential Diagnoses & Workup

Author: Catherine M Flaitz, DDS, MS, Professor of Oral and Maxillofacial Pathology and Pediatric Dentistry, Department of Diagnostic Sciences, University of Texas Health Sciences Center at Houston, Dental Branch
Coauthor(s): M John Hicks, DDS, MS, PhD, MD, Professor, Department of Pathology, Baylor College of Medicine; Medical Director of Ultrastructural Pathology, Medical Director of Cytogenetics and Molecular Cytogenetics, Department of Pathology, Texas Children's Hospital
Contributor Information and Disclosures

Updated: Jul 15, 2009

Differential Diagnoses

Branchial Cleft Cyst
Oral Hemangiomas
Dermoid Cyst
Oral Lymphangiomas
Lipomas
Oral Pyogenic Granuloma
Lymphangioma
Venous Lakes

Other Problems to Be Considered

Mucoceles may mimic the following:

Benign or malignant salivary gland neoplasms
Hemangioma
Lymphangioma
Venous varix or venous lake
Lipoma
Soft irritation fibroma
Oral lymphoepithelial cyst
Gingival cyst in adults
Soft tissue abscess
Cysticercosis (parasitic infection)

Anterior lingual mucoceles (Blandin-Nuhn mucoceles) may resemble the following:

Hemangioma
Pyogenic granuloma
Fibroepithelial polyp

Superficial mucoceles may be confused with the following:

Cicatricial pemphigoid
Bullous lichen planus
Recurrent herpes simplex infection
Minor aphthous ulcers (once lesions have ruptured)10

Oral ranula may resemble the following:

Benign or malignant salivary gland neoplasm
Dermoid cyst
Soft tissue space abscess
Hemangioma
Lymphangioma
Lipoma
Plexiform neurofibroma
Heterotopic gastrointestinal cyst

Cervical ranula may appear similar to the following:

Thyroglossal duct cyst
Branchial cleft cyst
Cystic hygroma15,16
Submandibular sialadenitis
Intramuscular hemangioma
Cystic or neoplastic thyroid disease
Infectious cervical lymphadenopathy (Epstein-Barr virus, cat scratch disease, tuberculosis)
Hematoma
Lipoma
Laryngocele
Dermoid cyst

A mucus retention cyst has a similar differential diagnosis as a mucocele and a ranula, depending on its location.

Workup

Imaging Studies

  • In general, imaging studies are not indicated in the evaluation of mucoceles and oral ranulas. Radiographic evaluation, in particular cross-sectional occlusal and panoramic films, are a consideration if sialoliths are a suspected contributing factor in the formation of oral and cervical ranulas.
  • Advanced imaging of the head and neck and mediastinum by CT scanning or MRI to define the extent of a cervical ranula and to eliminate other disease processes is prudent prior to surgical intervention.
  • Ultrasonography has also been used to evaluate the lesions.17

Procedures

  • Mucoceles usually require excisional biopsy and removal of the servicing minor salivary glands. If a vascular lesion cannot be excluded from the differential diagnosis, then aspiration of the lesion is prudent for evaluation of the fluid contents. Large mucoceles may be best treated by marsupialization because of the risk of traumatizing the labial branch of the mental nerve. Dissection of the lesion along with the adjacent salivary glands is indicated for moderate-sized lesions.
  • Superficial mucoceles may require biopsy, in addition to direct immunofluorescence studies for immunoglobulins and complement, if a mucocutaneous disease is suspected in the differential diagnosis. Laser vaporization may be useful when multiple lesions are present and a diagnosis has been established.18
  • Fine-needle aspiration of the contents of oral and cervical ranulas may be helpful in the diagnosis prior to excision and subsequent surgery. The fluid consists of mucus with muciphages (macrophages with engulfed mucin), as demonstrated by mucicarmine staining, and other inflammatory cells. Analysis of the aspirated fluid shows increased amylase and protein content. The recurrence of other fluid types or a solid mass with the failure to aspirate fluid indicates that a mass other than a ranula may have been encountered.
  • Oral and cervical ranulas require complete excision of the oral portion of the ranula, in addition to the responsible gland. Usually, the sublingual gland is the origin of the ranula; however, occasionally, the submandibular gland may be the source. Decompression of the oral ranula or the oral portion of a cervical ranula may be indicated. Some authors advocate marsupialization with packing of the pseudocyst with gauze. This technique allows removal of a smaller amount of tissue with better-defined interfaces and less likelihood of injury to the nerve and the Wharton duct. Likewise, some individuals advocate aspiration of the cervical portion of the plunging ranula.
  • Mucus retention cysts require excisional biopsy. If the retention cyst is overlying the Wharton or Stensen duct, the cyst is unroofed, a lacrimal probe is inserted into the duct, and sialodochoplasty is performed.

Histologic Findings

The mucocele and the oral ranula have a well-delineated cavity that contains free mucinous material; this material is characteristic of these entities. The cavity wall lacks an epithelial lining and is considered a pseudocyst. The pseudocyst wall is composed of granulation tissue with fibroblasts, proliferating small-caliber vessels, and a mixed acute and chronic inflammatory reaction. Muciphages are usually present in the fibroconnective wall of the pseudocyst. The muciphage cells may be demonstrated by using mucicarmine staining.

The cyst wall also has free mucin in the connective tissue stroma. The adjacent salivary gland tissue possesses dilated ducts, fibrosis, acinar atrophy, and chronic inflammation. Occasionally, a ruptured salivary duct that is feeding into the area may be identified. The mucosal surface may be atrophic with focal ulceration, or it may show epithelial hyperplasia with hyperkeratosis. Special stains, mucicarmine and Alcian blue, are useful in identifying mucin that is free in the tissue or in the foamy macrophages.

Extravasation of mucin along the mucosal-submucosal interface characterizes the superficial mucocele. The extravasation results in separation of the epithelium from its underlying submucosa and the formation of a subepithelial mucus-filled vesicle. A mild-to-moderate chronic inflammatory cell infiltration is observed in the underlying connective tissue, along with excretory ducts that may demonstrate ductal dilatation.

The cervical ranula appears identical to the mucus extravasation phenomenon. Biopsy of the lateral part of the neck may reveal only amorphous material with rare inflammatory cells, which stains positive for mucin.

The mucus retention cyst is a true cystic entity. It usually demonstrates a unicystic pattern; rarely, a multicystic appearance is identified. The cystic lining is composed of primarily cuboidal to columnar cells; however, mucous cells and squamous cells may be interspersed. Occasionally, oncocytoid and papillary changes of the epithelium lining are found. Typically, free mucin fills the central cavity, but mucus plugs and concentric layers of acellular calcification (sialolith) may be present. The cyst wall is composed of connective tissue with minimal inflammation, and it lacks the granular appearance of the mucus extravasation phenomenon. Atrophic sialadenitis with fibrosis and ductal ectasia may be found in the surrounding tissues.

Low-power photomicrograph of a mucocele with atte...

Low-power photomicrograph of a mucocele with attenuation of the mucosal surface and pooling of mucus (hematoxylin-eosin, original magnification X40).

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Low-power photomicrograph of a mucocele with atte...

Low-power photomicrograph of a mucocele with attenuation of the mucosal surface and pooling of mucus (hematoxylin-eosin, original magnification X40).



High-power photomicrograph of a mucocele with poo...

High-power photomicrograph of a mucocele with pooling of mucus and numerous foamy histiocytes (hematoxylin-eosin, original magnification X400).

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High-power photomicrograph of a mucocele with poo...

High-power photomicrograph of a mucocele with pooling of mucus and numerous foamy histiocytes (hematoxylin-eosin, original magnification X400).



Intermediate-power photomicrograph of an affected...

Intermediate-power photomicrograph of an affected minor salivary gland lobule with atrophy of the acinar structures, ductal ectasia, and fibrosis (hematoxylin-eosin, original magnification X100).

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Intermediate-power photomicrograph of an affected...

Intermediate-power photomicrograph of an affected minor salivary gland lobule with atrophy of the acinar structures, ductal ectasia, and fibrosis (hematoxylin-eosin, original magnification X100).

More on Mucocele and Ranula

Overview: Mucocele and Ranula
Differential Diagnoses & Workup: Mucocele and Ranula
Treatment & Medication: Mucocele and Ranula
Follow-up: Mucocele and Ranula
Multimedia: Mucocele and Ranula
References
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Further Reading

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Keywords

mucocele, ranula, plunging ranula, mucus retention phenomenon, mucus escape reaction, mucous cyst, cervical plunging ranula, oral ranula, anterior lingual mucocele, Blandin-Nuhn mucocele

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Contributor Information and Disclosures

Author

Catherine M Flaitz, DDS, MS, Professor of Oral and Maxillofacial Pathology and Pediatric Dentistry, Department of Diagnostic Sciences, University of Texas Health Sciences Center at Houston, Dental Branch
Catherine M Flaitz, DDS, MS is a member of the following medical societies: American Academy of Oral and Maxillofacial Pathology, American Academy of Oral Medicine, American Academy of Pediatric Dentistry, American Dental Association, International Association for Dental Research, and International Association of Oral Pathologists
Disclosure: Nothing to disclose.

Coauthor(s)

M John Hicks, DDS, MS, PhD, MD, Professor, Department of Pathology, Baylor College of Medicine; Medical Director of Ultrastructural Pathology, Medical Director of Cytogenetics and Molecular Cytogenetics, Department of Pathology, Texas Children's Hospital
M John Hicks, DDS, MS, PhD, MD is a member of the following medical societies: American Academy of Oral and Maxillofacial Pathology, American Society for Clinical Pathology, College of American Pathologists, International Academy of Pathology, and International Association of Oral Pathologists
Disclosure: Nothing to disclose.

Medical Editor

Timothy McCalmont, MD, Director, UCSF Dermatopathology Service, Professor of Clinical Pathology and Dermatology, Departments of Pathology and Dermatology, University of California at San Francisco
Timothy McCalmont, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, American Society of Dermatopathology, California Medical Association, College of American Pathologists, and United States and Canadian Academy of Pathology
Disclosure: Apsara Consulting fee Independent contractor

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Managing Editor

Drore Eisen, MD, DDS, Consulting Staff, Department of Dermatology, Dermatology Research Associates of Cincinnati
Drore Eisen, MD, DDS is a member of the following medical societies: American Academy of Dermatology, American Academy of Oral Medicine, and American Dental Association
Disclosure: Nothing to disclose.

CME Editor

Glen H Crawford, MD, Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital
Glen H Crawford, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Phi Beta Kappa, and Society of USAF Flight Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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