What is the treatment for a ranula?

Treatment of Ranula

For simple (intraoral) ranulas, transoral excision of the ipsilateral sublingual gland with ranula evacuation is the definitive treatment, yielding the lowest recurrence and complication rates at 3%. 1

Treatment Algorithm by Ranula Type and Size

Simple (Intraoral) Ranulas

First-line treatment:

• Excision of the ipsilateral sublingual gland with ranula evacuation is the gold standard, as nearly all ranulas are pseudocysts originating from the sublingual gland 2, 1
• This approach has only a 3% complication rate compared to 12% for ranula excision alone, 24% for marsupialization, and 82% for aspiration 1

Alternative for small, superficial lesions:

• Marsupialization can be considered for ranulas that are superficial, protruding, and smaller than 2 cm in diameter 2
• This technique is useful as a modification but carries higher recurrence risk (24% complication rate including recurrence) 1

Plunging (Cervical) Ranulas

Recommended approach:

• Cervical approach with excision of the sublingual gland is preferred 1
• The plunging component should be removed along with the sublingual gland (20% complication rate) or both sublingual and submandibular glands (33% complication rate) 1
• Transoral approach with sublingual gland removal and ranula evacuation can be attempted in select cases 1

Special Population: Infant Ranulas

Conservative initial management:

• For uncomplicated congenital ranulas in neonates and infants, observation for 6 months is reasonable as many resolve spontaneously 3, 4
• Aspiration of mucus can be performed during the observation period 3, 4

Stepwise escalation if recurrence occurs:

• If ranula recurs during observation: perform marsupialization 3
• If ranula recurs after marsupialization: perform surgical resection of ipsilateral sublingual gland when infant is approximately 1 year old 3
• During sublingual gland excision, careful dissection of the submandibular duct and complete sublingual nerve is essential before gland removal 3

Techniques to Avoid

High-failure interventions:

• Aspiration alone has an 82% complication/recurrence rate and should not be used as definitive treatment in adults 1
• Simple ranula excision without sublingual gland removal has a 12% complication rate versus 3% with gland excision 1
• OK-432 sclerotherapy has a 49% complication/recurrence rate 1

Key Surgical Considerations

Pathologic basis for treatment:

• Ranulas are pseudocysts without epithelial lining, representing mucus escape reactions from disrupted sublingual gland elements 2, 5
• Because the source is the sublingual gland, removing only the cyst leaves the pathologic gland in place, explaining high recurrence rates 2

Complications to monitor:

• Recurrence is the most prevalent complication (63% of all complications reported) 1
• Other complications include tongue hypesthesia (26%), bleeding/hematoma (7%), postoperative infection (3%), and Wharton's duct injury (1%) 1

Common Pitfalls

• Attempting marsupialization for large or deep ranulas increases recurrence risk; this technique should be reserved only for small (<2 cm), superficial, protruding lesions 2
• Performing aspiration as definitive treatment in adults leads to 82% failure rate 1
• Removing submandibular gland unnecessarily increases complication rates from 3% to 33% without improving outcomes for simple ranulas 1