Ranulas and Plunging Ranulas Treatment & Management

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.^[2]

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.

Ranulas

• Marsupialization: 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.
• Placement of suture or Seton: A silk suture or Seton can be placed through the surface of the cyst under local anesthesia. This is left in place 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 success has been good in limited studies. This can also be performed in the office.
• Sclerosing agents: Bleomycin and OK-432 have been used with success in treatment of ranulas. In one study, 31/32 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.
• Radiation therapy: 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.

Plunging ranulas

• Transoral approach: 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.
• Transcervical approach: 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.^[3]

Ranulas

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%).^[4] 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.

Plunging ranulas

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.

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.