Mucocele and Ranula Treatment & Management
- Author: Catherine M Flaitz, DDS, MS; Chief Editor: William D James, MD more...
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.[29, 30] 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. 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.
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. 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.[34, 35, 36]
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.
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.[37, 38]
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.
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.
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. Micromarsupialization has also used for the management of oral ranulas.[24, 25, 26]
The recurrence rates of an oral ranula with various surgical treatment methods are as follows :
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%
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.
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.
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.
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.
Depending on the extent of the procedure, strenuous physical and recreational activities are discouraged for several days to several weeks after surgery.
Harrison JD. Modern management and pathophysiology of ranula: literature review. Head Neck. 2010 Oct. 32(10):1310-20. [Medline].
Hoque MO, Azuma M, Sato M. Significant correlation between matrix metalloproteinase activity and tumor necrosis factor-alpha in salivary extravasation mucoceles. J Oral Pathol Med. 1998 Jan. 27(1):30-3. [Medline].
Azuma M, Tamatani T, Fukui K, et al. Proteolytic enzymes in salivary extravasation mucoceles. J Oral Pathol Med. 1995 Aug. 24(7):299-302. [Medline].
Crean SJ, Connor C. Congenital mucoceles: report of two cases. Int J Paediatr Dent. 1996 Dec. 6(4):271-5. [Medline].
Pownell PH, Brown OE, Pransky SM, Manning SC. Congenital abnormalities of the submandibular duct. Int J Pediatr Otorhinolaryngol. 1992 Sep. 24(2):161-9. [Medline].
Axell T. A prevalence study of oral mucosal lesions in an adult Swedish population. Odontol Revy. 1976. 27(36):1-103. [Medline].
Bessa CF, Santos PJ, Aguiar MC, do Carmo MA. Prevalence of oral mucosal alterations in children from 0 to 12 years old. J Oral Pathol Med. 2004 Jan. 33(1):17-22. [Medline].
Pang CE, Lee TS, Pang KP, Pang YT. Thoracic ranula: an extremely rare case. J Laryngol Otol. 2005 Mar. 119(3):233-4. [Medline].
Zhao YF, Jia Y, Chen XM, Zhang WF. Clinical review of 580 ranulas. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004 Sep. 98(3):281-7. [Medline].
Eveson JW. Superficial mucoceles: pitfall in clinical and microscopic diagnosis. Oral Surg Oral Med Oral Pathol. 1988 Sep. 66(3):318-22. [Medline].
Garcia-F-Villalta MJ, Pascual-Lopez M, Elices M, Dauden E, Garcia-Diez A, Fraga J. Superficial mucoceles and lichenoid graft versus host disease: report of three cases. Acta Derm Venereol. 2002. 82(6):453-5. [Medline].
Mandel L. Plunging ranula following placement of mandibular implants: case report. J Oral Maxillofac Surg. 2008 Aug. 66(8):1743-7. [Medline].
Chi AC, Lambert PR 3rd, Richardson MS, Neville BW. Oral mucoceles: a clinicopathologic review of 1,824 cases, including unusual variants. J Oral Maxillofac Surg. 2011 Apr. 69(4):1086-93. [Medline].
Campana F, Sibaud V, Chauvel A, Boiron JM, Taieb A, Fricain JC. Recurrent superficial mucoceles associated with lichenoid disorders. J Oral Maxillofac Surg. 2006 Dec. 64(12):1830-3. [Medline].
Mun SJ, Choi HG, Kim H, et al. Ductal variation of the sublingual gland: a predisposing factor for ranula formation. Head Neck. 2014 Apr. 36(4):540-4. [Medline].
Chidzonga MM, Rusakaniko S. Ranula: another HIV/AIDS associated oral lesion in Zimbabwe?. Oral Dis. 2004 Jul. 10(4):229-32. [Medline].
Syebele K, Bütow KW. Oral mucoceles and ranulas may be part of initial manifestations of HIV infection. AIDS Res Hum Retroviruses. 2010 Oct. 26(10):1075-8. [Medline].
Macdonald AJ, Salzman KL, Harnsberger HR. Giant ranula of the neck: differentiation from cystic hygroma. AJNR Am J Neuroradiol. 2003 Apr. 24(4):757-61. [Medline].
Osborne TE, Haller JA, Levin LS, Little BJ, King KE. Submandibular cystic hygroma resembling a plunging ranula in a neonate. Review and report of a case. Oral Surg Oral Med Oral Pathol. 1991 Jan. 71(1):16-20. [Medline].
Ali MK, Chiancone G, Knox GW. Squamous cell carcinoma arising in a plunging ranula. J Oral Maxillofac Surg. 1990 Mar. 48(3):305-8. [Medline].
La'porte SJ, Juttla JK, Lingam RK. Imaging the floor of the mouth and the sublingual space. Radiographics. 2011 Sep-Oct. 31(5):1215-30. [Medline].
Lesperance MM. When do ranulas require a cervical approach?. Laryngoscope. 2013 Aug. 123(8):1826-7. [Medline].
Yasumoto M, Nakagawa T, Shibuya H, Suzuki S, Satoh T. Ultrasonography of the sublingual space. J Ultrasound Med. 1993 Dec. 12(12):723-9. [Medline].
Woo SH, Chi JH, Kim BH, Kwon SK. Treatment of intraoral ranulas with micromarsupialization: Clinical outcomes and safety from a phase II clinical trial. Head Neck. 2013 Dec 22. [Medline].
Amaral MB, de Freitas JB, Mesquita RA. Upgrading of the micro-marsupialisation technique for the management of mucus extravasation or retention phenomena. Int J Oral Maxillofac Surg. 2012 Dec. 41(12):1527-31. [Medline].
Piazzetta CM, Torres-Pereira C, Amenábar JM. Micro-marsupialization as an alternative treatment for mucocele in pediatric dentistry. Int J Paediatr Dent. 2012 Sep. 22(5):318-23. [Medline].
Jinbu Y, Tsukinoki K, Kusama M, Watanabe Y. Recurrent multiple superficial mucocele on the palate: Histopathology and laser vaporization. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003 Feb. 95(2):193-7. [Medline].
Jia Y, Zhao Y, Chen X. Clinical and histopathological review of 229 cases of ranula. J Huazhong Univ Sci Technolog Med Sci. 2011 Oct. 31(5):717-20. [Medline].
McCaul JA, Lamey PJ. Multiple oral mucoceles treated with gamma-linolenic acid: report of a case. Br J Oral Maxillofac Surg. 1994 Dec. 32(6):392-3. [Medline].
Luiz AC, Hiraki KR, Lemos CA Jr, Hirota SK, Migliari DA. Treatment of painful and recurrent oral mucoceles with a high-potency topical corticosteroid: a case report. J Oral Maxillofac Surg. 2008 Aug. 66(8):1737-9. [Medline].
Mínguez-Martinez I, Bonet-Coloma C, Ata-Ali-Mahmud J, Carrillo-García C, Peñarrocha-Diago M, Peñarrocha-Diago M. Clinical characteristics, treatment, and evolution of 89 mucoceles in children. J Oral Maxillofac Surg. 2010 Oct. 68(10):2468-71. [Medline].
Zhi K, Wen Y, Ren W, Zhang Y. Management of infant ranula. Int J Pediatr Otorhinolaryngol. 2008 Jun. 72(6):823-6. [Medline].
Delbem AC, Cunha RF, Vieira AE, Ribeiro LL. Treatment of mucus retention phenomena in children by the micro-marsupialization technique: case reports. Pediatr Dent. 2000 Mar-Apr. 22(2):155-8. [Medline].
Jinbu Y, Kusama M, Itoh H, Matsumoto K, Wang J, Noguchi T. Mucocele of the glands of Blandin-Nuhn: clinical and histopathologic analysis of 26 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003 Apr. 95(4):467-70. [Medline].
Mintz S, Barak S, Horowitz I. Carbon dioxide laser excision and vaporization of nonplunging ranulas: a comparison of two treatment protocols. J Oral Maxillofac Surg. 1994 Apr. 52(4):370-2. [Medline].
Neumann RA, Knobler RM. Treatment of oral mucous cysts with an argon laser. Arch Dermatol. 1990 Jun. 126(6):829-30. [Medline].
Fukase S, Ohta N, Inamura K, Aoyagi M. Treatment of ranula wth intracystic injection of the streptococcal preparation OK-432. Ann Otol Rhinol Laryngol. 2003 Mar. 112(3):214-20. [Medline].
Roh JL, Kim HS. Primary treatment of pediatric plunging ranula with nonsurgical sclerotherapy using OK-432 (Picibanil). Int J Pediatr Otorhinolaryngol. 2008 Sep. 72(9):1405-10. [Medline].
Chow TL, Chan SW, Lam SH. Ranula successfully treated by botulinum toxin type A: report of 3 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008 Jan. 105(1):41-2. [Medline].
Baurmash HD. Marsupialization for treatment of oral ranula: a second look at the procedure. J Oral Maxillofac Surg. 1992 Dec. 50(12):1274-9. [Medline].
Zhao YF, Jia J, Jia Y. Complications associated with surgical management of ranulas. J Oral Maxillofac Surg. 2005 Jan. 63(1):51-4. [Medline].
Kim MG, Kim SG, Lee JH, Eun YG, Yeo SG. The therapeutic effect of OK-432 (picibanil) sclerotherapy for benign neck cysts. Laryngoscope. 2008 Dec. 118(12):2177-81. [Medline].
Wu CW, Kao YH, Chen CM, Hsu HJ, Chen CM, Huang IY. Mucoceles of the oral cavity in pediatric patients. Kaohsiung J Med Sci. 2011 Jul. 27(7):276-9. [Medline].