Mucocele and Ranula Treatment & Management

  • Author: Catherine M Flaitz, DDS, MS; Chief Editor: William D James, MD   more...
 
Updated: Feb 6, 2012
 

Medical Care

Examples of treating multiple superficial mucoceles with clobetasol 0.05%, a high-potency topical steroid, or with gamma-linolenic acid (oil of evening primrose), which is a prostaglandin E precursor, have some degree of success in limited patients.[23, 24] However, the lesions recur within a few months when gamma-linolenic acid is discontinued, while periodic use of the topical steroids is used to control flare-ups.

Mucoceles and ranulas may spontaneously resolve, especially in infants and young children. In a recent retrospective study, approximately 44% of mucoceles in children spontaneously resolved after an average of 3 months.[25] If symptoms are minimal in this young age group, aspiration of the lesions and periodic follow-up for 6 months have been suggested as an alternative to surgery.[26]

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Surgical Care

  • Mucus extravasation phenomenon: Surgical excision of the mucocele along with the adjacent associated minor salivary glands is recommended. The risk for recurrence is minimal when appropriate surgical excision has been performed. Aspiration only of the mucocele's contents often results in recurrence and is not appropriate therapy, except to exclude other entities prior to surgical excision. Large lesions may be marsupialized to prevent significant loss of tissue or to decrease the risk for significantly traumatizing the labial branch of the mental nerve. If the fibrous wall is thick, moderate-sized lesions may be treated by dissection. If this surgical approach is used, the adjacent minor salivary glands must be removed.
    • The use of a micromarsupialization technique for mucoceles in pediatric patients has been reported in a case series.[27] This technique involves the placement of a 4.0 silk suture through the widest diameter of the lesion (dome of the lesion) without engaging the underlying tissue. A surgical knot is made, and the suture is left in place for 7 days. Patients need to be educated about suture replacement; they must return to have the suture replaced if it should be lost during the 7-day period. The idea behind this alternative treatment for mucoceles of minor salivary glands is that re-epithelization of the severed duct occurs or a new epithelial-lined duct forms, allowing egress of saliva from the minor salivary gland. The recurrence rate after a short follow-up period has been 14% in pediatric patients. This technique is not indicated for lesions larger than 1 cm in diameter.
    • Laser ablation, cryosurgery, and electrocautery are approaches that have also been used for the treatment of the conventional mucocele with variable success.[28, 29, 30]
  • Superficial mucoceles: No surgical treatment is necessary unless the lesion frequently recurs and is problematic to the patient. If treatment is desired, the options include surgical excision, cryotherapy, and laser vaporization. To prevent recurrences when the lesion is associated with an underlying mucocutaneous disease, management of the causative disease is necessary.
  • Oral ranula: With most oral ranulas, surgical management is preferred. Isolated reports demonstrate that oral ranulas have been successfully treated with intracystic injection of the streptococcal preparation, OK-432. Lesion resolution or marked reduction was documented in almost all of the patients following this sclerotherapy. Local pain at the injection site and fever were noted in about 50% of the patients. Only limited studies have demonstrated the effectiveness of this management approach, and the results have been variable. Currently, the use of this sclerosing agent for the treatment of oral ranulas is considered experimental.[31, 32]
    • Another injectable drug used to treat ranulas is botulinum toxin A, which results in the denervation of the parasympathetic nerves responsible for salivation. Only a small case series has been reported on this novel, but experimental, treatment approach.[33]
    • Some clinicians use a tiered approach to the management of oral ranulas. The first attempt at management may be marsupialization of the ranula with packing of the entire pseudocyst with gauze for 7-10 days. The entire ranula is unroofed, and the packing material is firmly placed into the entire cavity of the pseudocyst. This technique allows for re-epithelialization of the pseudocyst cavity; seals the mucinous leak; and provokes a foreign body inflammatory reaction, leading to fibrosis and atrophy of the involved acini. The procedure may be effective with the sublingual gland because it has multiple draining excretory ducts. If this does not eliminate the ranula, additional surgical therapy is initiated with removal of the ranula and the offending major salivary gland.[34]
    • The more traditional method of surgery for an oral ranula is complete excision of the ranula and associated major salivary gland. Laser ablation and cryosurgery, either alone or after marsupialization, have been used for some patients with oral ranula.
    • The recurrence rates of an oral ranula with various surgical treatment methods are as follows[35] :
      • Incision and drainage, 71-100%
      • Ranula excision only, 0-25%
      • Marsupialization only, 61-89%
      • Marsupialization with packing, 0-12% (limited studies)
      • Complete excision of the ranula with the sublingual gland, 0-2%
  • Cervical ranula: The elimination of cervical ranulas depends on the complete surgical excision of the oral portion of the ranula with the associated sublingual salivary gland or, rarely, the submandibular gland.
    • When this procedure is performed, the cervical ranula resolves and has a low risk of recurrence. With drainage of the cervical ranula alone, the recurrence rate is greater than 85%. When the sublingual gland is intraorally excised along with drainage of the cervical pseudocyst, no recurrences are observed. A cervical approach to excision of the neck pseudocyst and the sublingual gland has a low recurrence rate (approximately 4%).
    • The most important factor in surgical management for cervical ranulas is removal of the responsible major salivary gland.
    • Besides surgical management, intracystic injection of the streptococcal preparation, OK-432, has been used to treat this lesion in a few case series, and the results have been variable. The use of this sclerosing agent as a treatment approach for the cervical ranula is considered experimental.[36]
  • Mucus retention cyst: These cysts are treated with conservative surgical excision. When they involve the major glands, partial or total removal of the affected gland may be necessary.
  • Guidelines: The American Academy of Pediatric Dentistry has surgical guidelines, Clinical guideline on pediatric oral surgery, that may be helpful.[37]
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Consultations

  • Consultation with a radiologist may be required to determine the tissue extension of oral and cervical ranulas.
  • Consultation with an anesthesiologist is recommended when airway obstruction is a possibility.
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Diet

Diet modifications depend on the extent of surgery.

  • After many oral surgical procedures, a liquid or soft and bland diet is usually recommended for the first couple of days.
  • More invasive surgeries that involve the removal of a major salivary gland may require a modified diet for a longer period.
  • Use of tobacco products is not recommended until healing has occurred.
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Activity

Depending on the extent of the procedure, strenuous physical and recreational activities are discouraged for several days to several weeks after surgery.

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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: Trimira, LLC Clinical contract for study Co-investigator on clinical grant; Trimira, LLC Honoraria Speaking and teaching; GC America Clinical contract for study Co-investigator on clinical grant

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.

Specialty Editor Board

Timothy McCalmont, MD  Director, UCSF Dermatopathology Service, Professor of Clinical Pathology and Dermatology, Departments of Pathology and Dermatology, University of California at San Francisco; Editor-in-Chief, Journal of Cutaneous Pathology

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

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.

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.

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

William D James, MD  Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology and Society for Investigative Dermatology

Disclosure: Elsevier Royalty Other

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Classic example of a mucocele in a child. The fluctuant, translucent-blue nodule on the lower labial mucosa has been present for 6 weeks. Trauma from sucking on the lower lip was suspected to be the cause.
Fluctuant submucosal nodule of the lower lip consistent with a mucocele.
Surgical excision of the mucocele in Media File 2.
Mucocele on the midline ventral surface of the tongue involving the glands of Blandin and Nuhn.
Example of 2 superficial mucoceles of the soft palate in a 50-year-old woman. The red lesion represents a recently ruptured mucocele, and the translucent papular lesion represents an intact mucocele.
Unilateral oral ranula in a young adult manifesting as a purple swelling.
Ranula on the floor of the mouth with focal ulceration.
Example of a cervical ranula with no oral involvement in an adult. The swelling developed after a car accident in which the individual had trauma to the face and neck.
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 pooling of mucus and numerous foamy histiocytes (hematoxylin-eosin, original magnification X400).
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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