What is the recommended first‑line treatment for a ranula (simple oral or plunging) and what alternative options are appropriate for a young child or a patient with significant comorbidities?

Ranula Treatment

First-Line Treatment Recommendation

For both simple oral and plunging ranulas, transoral excision of the ipsilateral sublingual gland with ranula evacuation is the definitive first-line treatment, yielding the lowest recurrence (0-3%) and complication rates compared to all other approaches. 1, 2

Treatment Algorithm by Ranula Type

Simple Oral Ranulas

Primary approach: Transoral excision of the sublingual gland with ranula evacuation 1

• This approach achieves only 3% complication rate (primarily recurrence) compared to 82% with aspiration alone, 24% with marsupialization, and 12% with ranula excision without gland removal 1
• Complete sublingual gland removal is critical—partial excision results in 25% recurrence rate versus 0% with complete excision 2
• The procedure avoids external scarring and can be performed without injury to Wharton's duct or lingual nerve when proper technique is used 3, 2

Special consideration for young children: Observation for 5 months may be appropriate as first-line management, as spontaneous resolution occurs in approximately 33% of pediatric cases 4

• If the lesion persists beyond 5 months or recurs after initial resolution, proceed directly to sublingual gland excision 4
• Do not attempt multiple marsupialization procedures in children, as this increases scar tissue and complicates definitive surgery 1

Plunging Ranulas

Primary approach: Transoral excision of the sublingual gland with evacuation of cervical cystic content 3, 2

• The intraoral approach achieves 0% recurrence with complete sublingual gland excision during median 14-36 month follow-up 3, 2
• This avoids external cervical scarring and the higher complication rate (33%) associated with transcervical approaches that include submandibular gland removal 1
• Complete excision of the sublingual gland is essential—partial excision results in 25% recurrence versus 0% with complete removal 2
• The cystic wall in the neck does not need to be completely dissected; evacuation of cystic fluid with complete sublingual gland removal is sufficient 3

Technical Execution Details

Critical Surgical Steps

• Identify and preserve the lingual nerve before beginning sublingual gland dissection to prevent permanent tongue numbness 4
• Dissect and relocate the submandibular (Wharton's) duct to enhance exposure to the floor of mouth and prevent duct injury 4
• Remove the entire sublingual gland—any residual glandular tissue significantly increases recurrence risk 1, 2
• For plunging ranulas, the cervical cyst wall rupture during intraoral dissection is expected and acceptable; complete cyst wall excision is not necessary 3

Expected Complications and Their Frequencies

Minor, temporary complications occur in approximately 5-9% of cases 2:

• Temporary tongue numbness: 5% 2
• Temporary dysgeusia: 9% 2
• Hematoma: 5% 2
• Temporary dysphagia: 5% 2

All complications resolve spontaneously without intervention 2

Management for Patients with Significant Comorbidities

For patients with bleeding disorders, significant cardiac disease, or conditions increasing anesthetic risk:

• Avoid sclerotherapy with OK-432, which has a 49% complication rate (primarily recurrence) and requires multiple injections 1
• Avoid marsupialization, which has 24% recurrence requiring repeat procedures under anesthesia 1
• Consider observation in pediatric patients, as 33% resolve spontaneously within 5 months 4
• When surgery is necessary, perform definitive sublingual gland excision in a single procedure rather than staged approaches, as this minimizes total anesthetic exposure 1, 2

Common Pitfalls to Avoid

• Do not perform aspiration alone—this has an 82% recurrence rate and subjects patients to repeated procedures 1
• Do not perform marsupialization as definitive treatment—24% recurrence rate makes this inadequate except as temporizing measure 1
• Do not remove the submandibular gland unless specifically indicated for submandibular pathology—this increases complication rates to 33% without improving ranula outcomes 1
• Do not use transcervical approach as first-line for plunging ranulas—the transoral approach achieves equivalent outcomes without external scarring 3, 2
• Do not attempt partial sublingual gland excision—this results in 25% recurrence versus 0% with complete excision 2