What is the recommended treatment for a plunging ranula?

Management of Plunging Ranula

The most effective treatment for plunging ranula is transoral complete excision of the sublingual gland with drainage of the ranula contents. 1, 2, 3

Diagnosis

Before proceeding with treatment, proper diagnosis is essential:

• Imaging: MRI is the most valuable method for correct diagnosis of plunging ranula 4

  • Characteristic appearance shows extension from sublingual space through mylohyoid muscle into submandibular space
  • CT scan can also be used for diagnosis
  • Ultrasound may be helpful for follow-up after treatment

• Clinical confirmation: Aspiration of saliva-like fluid from the cystic swelling 5

Treatment Algorithm

First-line Treatment

• Complete transoral excision of the sublingual gland with drainage of ranula contents
  • This approach has the lowest recurrence rate (0-7%) 1, 3
  • Provides definitive treatment with minimal complications 2
  • Essential to obtain complete resection of the gland to prevent relapse 1

Alternative Approaches (Not Recommended as First-line)

1. Partial sublingual gland excision

   • Higher recurrence rate (25%) compared to complete excision 3
   • Not recommended due to increased risk of recurrence

2. Transcervical approach

   • More invasive with higher complication rates (33%) 2
   • Should be reserved for cases where transoral approach is technically not feasible

3. Marsupialization alone

   • High recurrence rate (24%) 2
   • Not recommended for plunging ranulas

4. OK-432 (sclerotherapy)

   • High complication rate (49%) 2
   • May be considered in patients who are poor surgical candidates

5. Aspiration

   • Extremely high recurrence rate (82%) 2
   • Should only be used as a temporary measure

Potential Complications

The most common complications of surgical management include:

• Recurrence: Most common complication (varies by procedure) 2
• Tongue hypesthesia/numbness: Reported in up to 26% of cases 2, 3
• Dysgeusia: Reported in approximately 9% of cases 3
• Bleeding/hematoma: Occurs in about 5-7% of cases 2, 3
• Postoperative infection: Relatively rare (3-7%) 1, 2
• Wharton's duct injury: Rare complication (1%) 2

Follow-up

• Postoperative follow-up should include clinical examination and ultrasonography
• Complete resolution of the cyst typically occurs within two months after surgery 4
• Long-term follow-up (at least 6 months) is recommended to monitor for recurrence 1

Key Points for Success

• Complete (not partial) excision of the sublingual gland is crucial to prevent recurrence 3
• Careful identification and preservation of the lingual nerve and Wharton's duct during surgery is essential to avoid complications 3
• The transoral approach is preferred over transcervical approach for both effectiveness and reduced morbidity 2
• Proper preoperative imaging with MRI helps in accurate diagnosis and surgical planning 4

The evidence strongly supports that transoral complete excision of the sublingual gland with drainage of the ranula contents is the most effective treatment with the lowest recurrence and complication rates for plunging ranulas.