Mucocele and Ranula Workup
- Author: Catherine M Flaitz, DDS, MS; Chief Editor: William D James, MD more...
In general, imaging studies are not indicated in the evaluation of mucoceles and simple 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.[21, 22]
Ultrasonography has also been used to evaluate the lesions, especially oral ranulas.[23, 22]
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. The micromarsupialization technique and laser removal are additional treatment approaches.[24, 25, 26]
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.
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 affected also and only rarely is 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. Surgical management of plunging ranula usually involves surgical removal of the sublingual gland with cervical incision and drainage.
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.
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. Unusual variants include mucoceles with myxoglobulosis and papillary synovial metaplasia–like change.
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.
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].