Ranulas and Plunging Ranulas Treatment & Management
- Author: Brent Golden, DDS, MD; Chief Editor: Arlen D Meyers, MD, MBA more...
A recent study evaluated the effectiveness of orally administered Nickel Gluconate-Mercurius Heel-Potentised Swine Organ Preparations D10/D30/D200, a homotoxicological agent. This medication acts to stimulate pseudocyst reabsorption and glandular repairing, and aids in improving the physiologic functioning of the gland. In this study, Nickel Gluconate-Mercurius Heel-Potentised Swine Organ Preparations D10/D30/D200 was administered regularly from 6 weeks to 6 months. Eight out of 9 ranulas responded to medical therapy.
Congenital ranulas 
Some have advocated that all patients with submandibular duct obstruction leading to ranula formation need early marsupialization and ductoplasty to prevent complications such as sialoadenitis.
Evidence exists that imperforate ducts may spontaneously resolve if rupture takes place during feeding. Therefore, observation for spontaneous resolution of congenital ranulas is reasonable. If airway obstruction or feeding problems arise, surgery is indicated.
Simple marsupialization is the oldest and most widely reported treatment for ranulas. It involves unroofing the cyst and tacking the edges of the cyst to adjacent tissue. Failure rates range from 61-89%, with cysts recurring anywhere from 6 weeks to 12 months later. Inferior compression on the cyst from the tongue leads to premature closure of the opened cyst. This increases the risk of the cyst recurring. Packing the cyst cavity with gauze for 7-10 days improves the success rate. In one report, 11 of 12 patients had resolution of their ranula with marsupialization and subsequent packing of the cavity.
In a prospective study, Woo et al reported that micromarsupialization is an effective initial treatment for oral ranulas, with resolution of the ranulas occurring in all 20 of the trial’s patients. The ranulas recurred in five patients, with two patients again showing recurrence 6 months after revision, prompting resection of the ranula and sublingual gland.
Placement of suture or Seton
With micro-marsupialization, a silk suture or Seton can be placed through the surface of the ranula under local anesthesia. This is left in place a minimum of 7 days while an epithelial tract forms to allow for mucus drainage between the surface and the underlying salivary glandular tissue. Morbidity is minimal to nonexistent, and recurrence or treatment failure is the primary complication. This can also be performed in the office.
Bleomycin and OK-432 have been used with success in treatment of ranulas.[13, 14] In one study, 31 of 32 patients (97%) achieved a disappearance or marked reduction in ranula size with injection of OK-432. Nearly half of all patients experienced local pain or fever, which resolved over several days.
Carbon dioxide laser
The carbon dioxide laser has been used with limited patients with good success to remove the cyst and scar the gland enough to decrease risk for recurrence. A tissue biopsy is recommended first to confirm the diagnosis of ranula.
In the rare patient who cannot tolerate surgery, radiation therapy is a viable alternative. Low doses, from 20-25 grays (Gy), are effective. Xerostomia can be avoided with low-dose therapy and shielding of the contralateral parotid gland. The risk of radiation-induced malignancy is real but small.
Sublingual gland excision
The criterion standard for treatment of ranulas is excision of the sublingual gland. This removes the source of the mucus and thus significantly decreases the risk for recurrence. A review of 580 patients with ranulas and plunging ranulas found that recurrence rates varied greatly depending on the surgical method chosen. Marsupialization, excision of the ranula alone, and excision of the sublingual gland combined with the ranula resulted in recurrence rates of 66.67%, 57.69%, and 1.20% respectively.
This provides better access for complete removal of the sublingual gland. If ectopic sublingual gland is present on the cervical surface of the mylohyoid, this may be missed without exploring the undersurface of the muscle. Some surgeons advocate simply draining the cervical portion of the ranula and excising the gland transorally. Complete excision of the cyst is not necessary if the gland itself is excised. A biopsy of the cyst wall is recommended for tissue confirmation.
Yang and Hong reported in a prospective study that an intraoral surgical approach can safely and effectively be used to remove plunging ranulas. During the median 14-month follow-up period, none of the study’s 23 patients experienced a recurrence.
Complete removal of the sublingual gland is difficult with this approach, requiring division of the mylohyoid muscle and dissection up to the floor of the mouth. Some surgeons recommend a transoral excision of the gland with drainage of the cyst first. If that is unsuccessful, complete excision of the cyst via a transcervical approach is indicated. A transcervical approach is also indicated for ranulas located exclusively in the neck.
Some authors advocate the injection of methylene blue into the ranula at the start of the procedure to improve the preservation of vital surrounding structures. Care must be taken in injecting the dye to avoid extravasation into surrounding tissue.
Dilation and cannulation of the sublingual caruncle and submandibular duct (Wharton duct) with lacrimal probes is useful, when achievable, to accentuate the ductal course and prevent injury. The plane of dissection medially is of particular interest because of the lingual nerve and submandibular duct. Of note, the lingual nerve crosses the submandibular duct twice, coursing lateral to and under the duct before rising into the tongue medial to it.
Note the preoperative, intraoperative, and postoperative images below.
Risks include paraesthesia of the lingual nerve (up to 25% in some studies), injury to the Wharton duct with the possibility of obstructive sialadenitis, and ductal laceration leading to salivary leakage. In a study of 571 patients who underwent 606 procedures for ranulas, the most common complications included recurrence of the ranula (5.78%), lingual nerve injury resulting in sensory deficit of the tongue (4.89%), and damage to Wharton's duct (1.82%). Other complications included hematoma, infection, and dehiscence of the wound, all of which were uncommon. The tongue numbness generally resolves over the course of six months.
Risk for paresis and paralysis of the marginal mandibular nerve is increased because the nerve often lies just on the surface of the cyst. Drainage of the cyst following identification of the nerve can often reduce risk for postoperative complications.
Outcome and Prognosis
The overall risk for recurrence when the sublingual gland is not excised has been reported to be in excess of 50%. This rate drops to as low as 2% if the gland is excised. Because the risk to adjacent structures is higher for gland-excising procedures, a trial of less-invasive procedures is advocated by some. Smaller cysts (< 1.5 cm) are usually more superficial in nature and may respond more readily to marsupialization. Larger cysts are more closely associated with the gland and usually require gland excision in association with cyst removal.
Obtaining a specimen for pathology is essential, not only for histologic confirmation but also because the presence of squamous cell carcinoma arising in the cyst wall of a ranula and papillary cystadenocarcinoma of the sublingual gland presenting as a ranula have been reported.
Steelman R, Weisse M, Ramadan H. Congenital ranula. Clin Pediatr (Phila). 1998 Mar. 37(3):205-6. [Medline].
Morton RP, Ahmad Z, Jain P. Plunging ranula: congenital or acquired?. Otolaryngol Head Neck Surg. 2010 Jan. 142(1):104-7. [Medline].
Effat KG. Acute presentation of a plunging ranula causing respiratory distress: case report. J Laryngol Otol. 2012 Aug. 126(8):861-3. [Medline].
Jain R, Morton RP, Ahmad Z. Diagnostic difficulties of plunging ranula: case series. J Laryngol Otol. 2012 May. 126(5):506-10. [Medline].
Coit WE, Harnsberger HR, Osborn AG. Ranulas and their mimics: CT evaluation. Radiology. 1987 Apr. 163(1):211-6. [Medline].
Sumi M, Izumi M, Yonetsu K. Sublingual gland: MR features of normal and diseased states. AJR Am J Roentgenol. 1999 Mar. 172(3):717-22. [Medline].
Jain P, Jain R, Morton RP, Ahmad Z. Plunging ranulas: high-resolution ultrasound for diagnosis and surgical management. Eur Radiol. 2010 Jun. 20(6):1442-9. [Medline].
Garofalo S, Briganti V, Cavallaro S, Pepe E, Prete M, Suteu L. Nickel Gluconate-Mercurius Heel-Potentised Swine Organ Preparations: a new therapeutical approach for the primary treatment of pediatric ranula and intraoral mucocele. Int J Pediatr Otorhinolaryngol. 2007 Feb. 71(2):247-55. [Medline].
Matt BH, Crockett DM. Plunging ranula in an infant. Otolaryngol Head Neck Surg. 1988 Sep. 99(3):330-3. [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].
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. 2015 Feb. 37 (2):197-201. [Medline].
Morton RP, Bartley JR. Simple sublingual ranulas: pathogenesis and management. J Otolaryngol. 1995 Aug. 24(4):253-4. [Medline].
Fukase S, Ohta N, Inamura K. Treatment of Ranula with Intracystic Injecton of the Streptococcal Preparation OK-432. Ann Otol Rhinol Laryngol. 2003. 112(3):214-20. [Medline].
Ikarashi T, Inamura K, Kimura Y. Cystic lymphangioma and plunging ranula treated by OK-432 therapy: a report of two cases. Acta Otolaryngol Suppl. 1994. 511:196-9. [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].
Shimm DS, Berk FK, Tilsner TJ. Low-dose radiation therapy for benign salivary disorders. Am J Clin Oncol. 1992 Feb. 15(1):76-8. [Medline].
Yoshimura Y, Obara S, Kondoh T. A comparison of three methods used for treatment of ranula. J Oral Maxillofac Surg. 1995 Mar. 53(3):280-2; discussion 283. [Medline].
Zhao Y, Jia Y, Chen X. Clinical Review of 580 Ranulas. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004. 98(3):281-7. [Medline].
Yang Y, Hong K. Surgical results of the intraoral approach for plunging ranula. Acta Otolaryngol. 2014 Feb. 134 (2):201-5. [Medline].
Cochran CS, Zhou CQ, DeFatta RJ, Adelson RT. An innovative method of facilitating ranula excision with methylene blue injection. Ear Nose Throat J. March 2006. 85(3):159, 163. [Medline].
Zhao Y, Jia J, Jia Y. Complications Associated with Surgical Management of Ranulas. J Oral Malillofac Surg. 2005. 63:51-54. [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].
Danford M, Eveson JW, Flood TR. Papillary cystadenocarcinoma of the sublingual gland presenting as a ranula. Br J Oral Maxillofac Surg. 1992 Aug. 30(4):270-2. [Medline].