What does a ranula look like and how is it treated?

Ranula: Clinical Appearance and Management

I cannot provide images, but I can describe what a ranula looks like and how it should be treated based on current evidence.

Clinical Appearance

A ranula presents as a painless, slow-growing, soft, and movable mass located in the floor of the mouth, typically appearing as a translucent bluish swelling. 1

Key Visual Characteristics:

• Simple (intraoral) ranula: Presents as a mass confined to the floor of the mouth, limited to the mucous membranes, with a characteristic translucent or bluish appearance due to the thin overlying mucosa 1
• Plunging (diving) ranula: Extends through the facial planes, usually posterior to the mylohyoid muscle into the neck, presenting as a cervical mass in the submandibular triangle 1, 2
• The lesion is a diffuse swelling caused by either mucous extravasation or, less commonly, a mucous retention cyst derived from the sublingual or submandibular salivary glands 1

Diagnostic Imaging

MRI is the most valuable imaging modality for correctly diagnosing plunging ranula and differentiating it from other neck masses. 2

Imaging Recommendations:

• MRI provides characteristic signs that enable accurate diagnosis and help distinguish ranula from thyroglossal duct cyst, branchial cleft cyst, cystic hygroma, submandibular sialadenitis, intramuscular hemangioma, or cystic thyroid disease 2
• Ultrasonography is useful for post-treatment monitoring to confirm cyst regression 2

Treatment Algorithm

For simple intraoral ranulas, the definitive treatment is total removal of the ipsilateral sublingual gland, which provides the most reliable cure with lowest recurrence rates. 2

Treatment Strategy by Patient Age and Presentation:

Infant Patients (< 1 year old): 3

• Initial management: Aspiration of mucus with 6-month observation period for spontaneous resolution
• If recurrence occurs: Marsupialization
• If recurrence persists: Surgical resection of ipsilateral sublingual gland when patient reaches approximately 1 year of age
• This conservative approach is safe, with complete sublingual nerve and submandibular duct dissection performed before gland removal 3

Adult Patients with Simple Ranula:

• Primary treatment: Total removal of the sublingual gland with evacuation of cystic contents via intraoral approach 2
• The cyst gradually regresses and disappears within 2 months after surgery 2

Alternative Treatment - Sclerotherapy: 4

• Bleomycin intralesional injection is 100% effective for ranulas originating from the lesser sublingual gland (LSLG) and Rivini duct (median 1.16 injections required) 4
• Critical caveat: This approach is completely ineffective for ranulas from the greater sublingual gland (GSLG), with 0% cure rate 4
• Before treatment, determine the cyst origin by characterizing its morphology to ensure appropriate therapy selection 4

Procedures with Higher Recurrence Risk:

• Marsupialization alone has variable recurrence rates 1
• Simple excision of the ranula without removing the sublingual gland carries higher recurrence risk 1
• Aspiration alone may provide temporary relief but typically results in recurrence unless the patient is an infant with potential for spontaneous resolution 3, 5

Common Pitfalls to Avoid

• Do not perform sclerotherapy for GSLG-origin ranulas - it will fail; surgical excision is required 4
• Misdiagnosis of plunging ranula as other neck masses inevitably leads to incorrect treatment; obtain MRI for definitive diagnosis 2
• In infants, avoid premature surgical intervention - many congenital ranulas resolve spontaneously and should be observed for several months in uncomplicated cases 5
• Incomplete removal of the sublingual gland leads to recurrence; ensure complete gland excision 2