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. [40, 41] 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 retrospective study, approximately 44% of mucoceles in children spontaneously resolved after an average of 3 months. [14] 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. [42] Although there is minimal evidence to support the use of intralesional steroids for the management of oral mucoceles, this treatment option may be an alternative when surgery cannot be performed. [43]
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. [44] 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. 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. [45, 46, 47]
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.
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. [48, 49]
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. [50]
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. [51]
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. [31, 32, 33]
Routine postsurgical care is required for patients who undergo the surgical procedure under general anesthesia. Typical wound care after surgical management is required. Patients who receive marsupialization with gauze packing should be informed that the dressing is spontaneously expelled in 7-14 days.
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.
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. [52]
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.
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.
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.
Activity
Depending on the extent of the procedure, strenuous physical and recreational activities are discouraged for several days to several weeks after surgery.
Complications
A low risk of bleeding and low-to-moderate peripheral nerve damage exists after excision of a mucocele. The potential for nerve damage is reduced during mucocele excision by initiation of proper incision direction. Further, mucocele reoccurrence is reduced if the gland and adjacent glandular tissue are removed in entirety.
No complications are associated with superficial mucoceles, unless the lesions are surgically excised.
Complications are more common with surgical intervention in oral and cervical ranulas than other treatments. Possible surgical complications include the following: injury to the Wharton duct, leading to stenosis, obstructive sialadenitis, and leakage of saliva; injury to the lingual nerve with temporary or permanent paresthesia; and injury to the marginal mandibular branch of the facial nerve with paresthesia. Postoperative hematoma, infection, or dehiscence of the wound may occur.
In addition, incomplete removal of the oral ranula increases the risk for developing a cervical ranula, while a cervical ranula may extend into the mediastinum. Approximately 45% of plunging ranulas occur after attempts to remove oral ranulas, which can result in a compromised airway. Cervical ranulas can extend into the mediastinum and provoke a sterile mediastinitis that may be life threatening.
The complications of a mucus retention cyst are the same as those for a mucus retention phenomenon and an oral ranula, depending on the location.
Prevention
Avoidance of local trauma to the minor salivary glands may help to prevent the development of oral mucoceles. Although unanticipated injury to the mouth is difficult to predict, habits that irritate the minor salivary glands such as sucking or chewing on the lips or tongue may be contributing factors. Constant rubbing of the oral mucosa against sharp or fractured teeth or orthodontics appliances is a potential cause. The discontinuation of contributing habits, restoration of damaged teeth, judicious use of orthodontic wax with oral appliances, and wearing mouthguards in sports should be encouraged to prevent oral irritations that could lead to the rupture and spillage of mucin into the surrounding mucosa.
Superficial mucoceles can be prevented by treating the mucosal disease causing these lesions to develop, including chronic mucocutaneous diseases and contact allergies. When xerostomia is a contributing factor, recommend maintaining a moist oral environment through hydration and, if necessary, oral moisturizers or lubricants.
Long-Term Monitoring
Mucus extravasation phenomenon
In general, the recurrence rate of mucus extravasation phenomenon following surgical excision is low (approximately 8%). [14] However, the location, and the age of the patient, influence this risk. In particular, the ventral tongue has a higher recurrence rate (50%), while younger patients (< 30 years) have a higher risk (16%) in comparison to older individuals (4%). [53] When micromarsupialization is performed, the recurrence rate after a short follow-up period has been 14% in pediatric patients. [44] A similar recurrence rate of 14% has been documented with laser treatment. [53] Continued irritation or trauma to the affected tissues or incomplete removal of the feeder minor glands is the suspected cause of recurrences.
Superficial mucoceles
The recurrence rate for superficial mucoceles is high (approximately 50%), despite surgical removal. Because these lesions are often multiple in number, the excised lesion may not represent a recurrences but rather a new or undiagnosed concurrent lesion. To prevent recurrences when the lesion is associated with an underlying mucocutaneous disease, management of the causative disease is necessary.
Oral ranula
The recurrence rates of an oral ranula is variable depending on the size of the lesion and the surgical procedure performed. The rates of recurrence with various surgical treatment methods are as follows [54] :
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Incision and drainage, 71-100%
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Ranula excision only, 0-25%
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Marsupialization only, 61-89%
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Marsupialization with packing, 0-12% (limited studies)
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Complete excision of the ranula with the sublingual gland, 0-2%
In a 2019 proportion meta-analysis, intraoral resection of the of the sublingual gland had the highest cure rate for oral ranulas (98.8%). [55] Similarly, micromarsupialization and its modifications showed a cure rate of 93.85%, but moderate inconsistencies in the cure rates were found.
Cervical ranula
When the responsible major salivary gland is removed, 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%). In a 2019 proportion meta-analysis, oral and cervical resection of a cervical ranula did not show significant differences in the cure rate based on the surgical approach—intraoral was 98.95% and cervical was 91.51%. [55]
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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.
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Fluctuant submucosal nodule of the lower lip consistent with a mucocele.
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Surgical excision of the mucocele in Media File 2.
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Mucocele on the midline ventral surface of the tongue involving the glands of Blandin and Nuhn.
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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.
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Unilateral oral ranula in a young adult manifesting as a purple swelling.
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Ranula on the floor of the mouth with focal ulceration.
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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.
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Low-power photomicrograph of a mucocele with attenuation of the mucosal surface and pooling of mucus (hematoxylin-eosin, original magnification X40).
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High-power photomicrograph of a mucocele with pooling of mucus and numerous foamy histiocytes (hematoxylin-eosin, original magnification X400).
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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).
