Management of Ranula
The initial approach to treating a ranula should be observation for spontaneous resolution for up to 6 months, followed by marsupialization if the ranula persists, and ultimately surgical excision of the ranula with the ipsilateral sublingual gland if recurrence occurs.
Understanding Ranulas
A ranula is a pseudocyst or mucocele that forms in the floor of the mouth due to extravasation of mucus from the sublingual gland or obstruction of the sublingual duct. They can be classified into:
- Simple (oral) ranula: Confined to the floor of the mouth
- Plunging ranula: Extends below the mylohyoid muscle into the neck
- Mixed ranula: Has both oral and plunging components
Initial Diagnostic Approach
Before initiating treatment, proper diagnosis is essential:
- Imaging: Ultrasound is the recommended diagnostic tool to define the anatomy and relationship to surrounding structures 1
- Clinical examination: Assess the size, location, and whether it's a simple or plunging ranula
Treatment Algorithm
Step 1: Observation and Aspiration (First-line approach)
- Observe for spontaneous resolution for up to 6 months 2, 3
- Aspiration of mucus can be performed as a temporary measure during the observation period 2
- This approach is particularly appropriate for infant patients and simple ranulas
Step 2: Marsupialization (If ranula persists after observation)
- Marsupialization has a success rate of approximately 85% 1
- This is a minimally invasive procedure with lower complication rates
- Recurrence rate after marsupialization is approximately 13% 1
Step 3: Surgical Excision with Sublingual Gland Removal (For recurrent cases)
- Complete excision of the ranula with the ipsilateral sublingual gland has the lowest recurrence rate (3.6%) 1, 4
- This should be performed when the ranula recurs after marsupialization
- For pediatric patients, this is recommended when the child is approximately 1 year old if the ranula has recurred 2
Comparative Success Rates of Different Approaches
| Treatment Approach | Recurrence Rate |
|---|---|
| Complete sublingual gland excision | 3.6% [1] |
| Partial sublingual gland excision | 9.1% [1] |
| Marsupialization | 13% [1] |
| Ranula excision alone | 36.7% [1] |
Special Considerations
For Plunging Ranulas
- OK-432 sclerotherapy may be considered as an alternative to surgery with a success rate of approximately 85% 5
- This involves aspiration of the cystic contents followed by injection of OK-432 solution
For Pediatric Patients
- More conservative approaches are preferred initially
- Spontaneous resolution should be given time (up to 5-6 months) 2, 3
- If surgical intervention is needed, careful identification and preservation of the submandibular duct and lingual nerve is essential 2, 3
Technical Surgical Considerations
When performing surgical excision:
- The submandibular duct and lingual nerve should be identified and preserved
- Complete removal of the sublingual gland is crucial to prevent recurrence
- An intraoral approach is generally preferred for both simple and plunging ranulas 4
Complications to Monitor
- Fever and swelling (common but temporary)
- Lingual nerve injury (rare)
- Recurrence (most common with ranula excision alone)
- Odynophagia (difficulty or pain when swallowing)
The evidence clearly demonstrates that while more conservative approaches may be appropriate initially, complete excision of the sublingual gland offers the most definitive treatment with the lowest recurrence rate for persistent or recurrent ranulas.