A ranula (Latin word rana, meaning frog) describes a
blue, translucent swelling in the floor of the mouth,
reminiscent of the underbelly of a frog. It is an
uncommon type of mucus-filled cyst (mucocœle)
arising from the sublingual or submandibular salivary
glands in the floor of the mouth.
|Ranulas / Ranulæ
& Their Treatment
Photos of ranulæ
present in the floor
of the mouth, either
sides (opposite) or
just one side
The structure is essentially the same as other mucocœles, though there is usually
an epithelial lining (i.e. lined by ‘skin’).
Ranulæ are usually either one-side or the other in the floor of the mouth and 2 - 3
cm in diameter. Occasionally, they extend across the whole of the floor of the
A ranula is most commonly observed as a bluish cyst located below the tongue. It
may fill the mouth and raise the tongue. Typically, these are painless masses that
do not change in size in response to chewing, eating or swallowing but may
interfere with these functions (speech or chewing / eating). Occasionally, pain may
Ranulæ are rare. In one study of 1303 salivary gland cysts, only 42 were ranulæ.
The reported male-to-female ratio of occurrence is 1:1.3. Ranulæ tends to occur
most frequently in the second and third decades of life, with an age range of 3 - 61
Ranulæ are formed from 1 of 2 processes:
1. Partial obstruction of a sublingual duct can lead to formation of an
epithelial-lined retention cyst. This is unusual, occurring in less than 10% of all
2. Trauma can lead to formation of ranulæ. With trauma, if a duct is
obstructed, secretory back-pressure builds leading to salivary duct rupture with
mucus being forced into the surrounding tissues. Alternately, trauma causes direct
damage to the duct or acini, leading to mucus extravasation - a pseudocyst then
forms. The more appropriate term for this may be Mucus Escape Reaction (MER).
MRI is the most sensitive imaging study to evaluate the sublingual gland and its
Sublingual glands and their pathologic states are difficult to visualise with ultra-
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.
A recent though small study evaluated the effectiveness of orally administered
Nickel Gluconate-Mercurius Heel-Potentised Swine Organ Preparations
D10/D30/D200, a homo-toxicological agent.
This medication acts to stimulate pseudocyst re-absorption and glandular repair
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 ranulæ
responded to medical therapy.
Marsupialisation: Simple marsupialisation is the oldest and most widely reported
treatment for ranulæ. 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 leading to the high recurrence rates. When conventional
marsupialisation is undertaken, the wound margins tend to be in contact with
each other because of the narrow space and the movement of the tongue and the
floor of the mouth. As a result, the ranula tends to re-form and recur.
Packing the cyst cavity with gauze for 7 - 10 days improves the success rate.
Placement of suture / stitch or Seton: A silk suture or Seton can be placed through
the surface of the cyst under local anæsthesia. 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 non-existent and success has been good in limited studies.
Sclerosing Agents: Bleomycin and OK-432 have been used with success in
treatment of ranulæ.
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. Intra-cystic injection therapy with
OK-432 is relatively safe and can be used as a substitute for surgery in the
treatment of ranulæ. Intra-cystic sclerosing injection with OK-432 has been
proposed as a ranula primary treatment.
CO2 Laser: The CO2 laser has been used with a limited number of patients with
good success to remove the cyst and scar the gland enough to decrease risk for
Post-operative follow-up at 6 months showed no recurrence, no lingual nerve
dysæsthesia, no ductal disruption and only minimal scar formation.
Radiation Therapy: In the rare patient who cannot tolerate surgery, radiation
therapy is a viable alternative. Low doses are effective. Xerostomia (dry mouth)
can be avoided with low-dose therapy and shielding of the opposite side parotid
gland. The risk of radiation-induced malignancy is real but small.
Sublingual Gland Excision: The 'gold-standard' treatment for ranulæ is the excision
of the ranula & the sublingual gland. This removes the source of the mucus and
thus significantly decreases the risk for recurrence.
A ranula larger than 1 cm should be treated by removal of the offending sublingual
gland; other authors have proposed that this treatment be used regardless of the
size of the lesion.
Marsupialisation, 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.
|Last Updated 17th October 2013