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Ranula
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.
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
occupying both
sides (opposite)
or just one side
(below).
present in the
floor of the
mouth, either
occupying both
sides (opposite)
or just one side
(below).
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 mouth.
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 be involved.
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 years.
Ranula Formation
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 ranulæ.
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).
Ranula Investigations
MRI is the most sensitive imaging study to evaluate the
sublingual gland and its pathologic states.
Sublingual glands and their pathologic states are difficult
to visualise with ultra-sound.
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.
Medical Treatment
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.
Surgical Treatment
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
recurrence.
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.
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 mouth.
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 be involved.
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 years.
Ranula Formation
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 ranulæ.
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).
Ranula Investigations
MRI is the most sensitive imaging study to evaluate the
sublingual gland and its pathologic states.
Sublingual glands and their pathologic states are difficult
to visualise with ultra-sound.
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.
Medical Treatment
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.
Surgical Treatment
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
recurrence.
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.
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 as the dye can leak into (non-ranula)
surrounding tissue and be misleading to the surgeon.
Complications
Ranula surgical treatment involves the following risks:
Baurmash recommended that ranulæ be treated
initially by marsupialisation with packing and, if recurrence
occurs, the offending sublingual gland should then be
excised.
The essential treatment of a ranula was meticulous
dissection of the thin wall of the cyst in continuity with the
sublingual gland of origin. They used a technique of
fibrin glue injection into the cystic space of the ranula
after it had been evacuated by aspiration. The fibrin glue
within the cystic cavity prevents collapse of the wall of
the cyst during surgery and facilitates and simplifies the
surgical procedure by clearly outlining the involved area
and by sharply delineating its thin wall.
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. As 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
marsupialisation. Larger cysts are more closely
associated with the gland and usually require gland
excision in association with cyst removal.
Useful Articles:
Eur J Plast Surg 2002 - OK-432 injection therapy for
plunging ranula
Lasers in Medical Science 2004. Surgical Treatment of
ranula with carbon dioxide radiation
J Oral Maxillofac Surg 2005 - Complications Associated
with Surgical Management of Ranulas
Am J Neuroradiol 2006. OK-432 Sclerotherapy of
Plunging Ranula in 21 Patients - It Can Be A Substitute
for Surgery?
J Oral Maxillofac Surg 2007. Clinical Controversies in
Oral & Maxillofacial Surgery. Part 1. Management of the
Ranula
J Oral Maxillofac Surg 2008. Conservative Treatment of
Oral Ranula by Excision With Minimal Excision of the
Sublingual Gland
The Laryngoscope 2009. Transoral Approach for
Plunging Ranula — 10-Year Experience
Useful Websites:
Emedicine (ENT)
Emedicine (Dermatology)
into the ranula at the start of the procedure to improve
the preservation of vital surrounding structures. Care
must be taken as the dye can leak into (non-ranula)
surrounding tissue and be misleading to the surgeon.
Complications
Ranula surgical treatment involves the following risks:
- recurrence of the ranula (especially when the
sublingual gland was not removed). - damage to the lingual nerve resulting in paræsthesia
(numbness) of the nerve (up to 25% in some
studies). The tongue numbness generally resolves
over the course of six months. - injury to the Wharton duct with the possibility of
obstructive sialadenitis and ductal laceration leading
to salivary leakage. - severe hæmorrhage from the lingual and sublingual
vasculature - post-operative hæmatoma
- partial dehiscence of the wound
- post-operative infection
Baurmash recommended that ranulæ be treated
initially by marsupialisation with packing and, if recurrence
occurs, the offending sublingual gland should then be
excised.
The essential treatment of a ranula was meticulous
dissection of the thin wall of the cyst in continuity with the
sublingual gland of origin. They used a technique of
fibrin glue injection into the cystic space of the ranula
after it had been evacuated by aspiration. The fibrin glue
within the cystic cavity prevents collapse of the wall of
the cyst during surgery and facilitates and simplifies the
surgical procedure by clearly outlining the involved area
and by sharply delineating its thin wall.
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. As 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
marsupialisation. Larger cysts are more closely
associated with the gland and usually require gland
excision in association with cyst removal.
Useful Articles:
Eur J Plast Surg 2002 - OK-432 injection therapy for
plunging ranula
Lasers in Medical Science 2004. Surgical Treatment of
ranula with carbon dioxide radiation
J Oral Maxillofac Surg 2005 - Complications Associated
with Surgical Management of Ranulas
Am J Neuroradiol 2006. OK-432 Sclerotherapy of
Plunging Ranula in 21 Patients - It Can Be A Substitute
for Surgery?
J Oral Maxillofac Surg 2007. Clinical Controversies in
Oral & Maxillofacial Surgery. Part 1. Management of the
Ranula
J Oral Maxillofac Surg 2008. Conservative Treatment of
Oral Ranula by Excision With Minimal Excision of the
Sublingual Gland
The Laryngoscope 2009. Transoral Approach for
Plunging Ranula — 10-Year Experience
Useful Websites:
Emedicine (ENT)
Emedicine (Dermatology)
| Last Updated 2nd March 2011 |
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