15/1/2018 Mucocele and Ranula Treatment & Management: Approach Considerations, Medical Care, Surgical Care

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Mucocele and Ranula Treatment &

Management
Updated: Jul 14, 2017
Author: Catherine M Flaitz, DDS, MS; Chief Editor: Jeff Burgess, DDS, MSD more...

TREATMENT

Approach Considerations
Surgical excision with the submission of the tissue for histopathologic examination is the treatment of
choice for persistent oral mucoceles and ranulas.

Medical Care
Examples of treating multiple superficial mucoceles with clobetasol 0.05%, a high-potency topical
steroid, or with gamma-linolenic acid (oil of evening primrose), which is a prostaglandin E precursor,
have some degree of success in limited patients. [35, 36] However, the lesions recur within a few
months when gamma-linolenic acid is discontinued, while periodic use of the topical steroids is used
to control flare-ups.

Mucoceles and ranulas may spontaneously resolve, especially in infants and young children. In a
retrospective study, approximately 44% of mucoceles in children spontaneously resolved after an
average of 3 months. [10] If symptoms are minimal in this young age group, aspiration of the lesions
and periodic follow-up for 6 months have been suggested as an alternative to surgery. [37] Although
there is minimal evidence to support the use of intralesional steroids for the management of oral
mucoceles, this treatment option may be an alternative when surgery cannot be performed. [38]

Surgical Care
Mucus extravasation phenomenon
Surgical excision of the mucocele along with the adjacent associated minor salivary glands is
recommended. The risk for recurrence is minimal when appropriate surgical excision has been
performed. Aspiration only of the mucocele's contents often results in recurrence and is not
appropriate therapy, except to exclude other entities prior to surgical excision. Large lesions may be
marsupialized to prevent significant loss of tissue or to decrease the risk for significantly traumatizing
the labial branch of the mental nerve. If the fibrous wall is thick, moderate-sized lesions may be
treated by dissection. If this surgical approach is used, the adjacent minor salivary glands must be
removed.

The use of a micromarsupialization technique for mucoceles in pediatric patients has been reported in
a case series. [39] This technique involves the placement of a 4.0 silk suture through the widest
diameter of the lesion (dome of the lesion) without engaging the underlying tissue. A surgical knot is
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made, and the suture is left in place for 7 days. Patients need to be educated about suture
replacement; they must return to have the suture replaced if it should be lost during the 7-day period.
The idea behind this alternative treatment for mucoceles of minor salivary glands is that re-
epithelization of the severed duct occurs or a new epithelial-lined duct forms, allowing egress of saliva
from the minor salivary gland. This technique is not indicated for lesions larger than 1 cm in diameter.

Laser ablation, cryosurgery, and electrocautery are approaches that have also been used for the
treatment of the conventional mucocele with variable success. [40, 41, 42]

Superficial mucoceles
No surgical treatment is necessary unless the lesion frequently recurs and is problematic to the
patient. If treatment is desired, the options include surgical excision, cryotherapy, and laser
vaporization.

Oral ranula

With most oral ranulas, surgical management is preferred. Isolated reports demonstrate that oral
ranulas have been successfully treated with intracystic injection of the streptococcal preparation, OK-
432. Lesion resolution or marked reduction was documented in almost all of the patients following this
sclerotherapy. Local pain at the injection site and fever were noted in about 50% of the patients. Only
limited studies have demonstrated the effectiveness of this management approach, and the results
have been variable. Currently, the use of this sclerosing agent for the treatment of oral ranulas is
considered experimental. [43, 44]

Another injectable drug used to treat ranulas is botulinum toxin A, which results in the denervation of
the parasympathetic nerves responsible for salivation. Only a small case series has been reported on
this novel, but experimental, treatment approach. [45]

Some clinicians use a tiered approach to the management of oral ranulas. The first attempt at
management may be marsupialization of the ranula with packing of the entire pseudocyst with gauze
for 7-10 days. The entire ranula is unroofed, and the packing material is firmly placed into the entire
cavity of the pseudocyst. This technique allows for re-epithelialization of the pseudocyst cavity; seals
the mucinous leak; and provokes a foreign body inflammatory reaction, leading to fibrosis and atrophy
of the involved acini. The procedure may be effective with the sublingual gland because it has multiple
draining excretory ducts. If this does not eliminate the ranula, additional surgical therapy is initiated
with removal of the ranula and the offending major salivary gland. [46]

The more traditional method of surgery for an oral ranula is complete excision of the ranula and
associated major salivary gland. Laser ablation and cryosurgery, either alone or after marsupialization,
have been used for some patients with oral ranula. Micromarsupialization has also used for the
management of oral ranulas. [26, 27, 28]

Routine postsurgical care is required for patients who undergo the surgical procedure under general
anesthesia. Typical wound care after surgical management is required. Patients who receive
marsupialization with gauze packing should be informed that the dressing is spontaneously expelled in
7-14 days.

Cervical ranula
The elimination of cervical ranulas depends on the complete surgical excision of the oral portion of the
ranula with the associated sublingual salivary gland or, rarely, the submandibular gland.

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Besides surgical management, intracystic injection of the streptococcal preparation, OK-432, has
been used to treat this lesion in a few case series, and the results have been variable. The use of this
sclerosing agent as a treatment approach for the cervical ranula is considered experimental. [47]

Mucus retention cyst

These cysts are treated with conservative surgical excision. When they involve the major glands,
partial or total removal of the affected gland may be necessary.

Consultations
Consultation with a radiologist may be required to determine the tissue extension of oral and cervical
ranulas.

Consultation with an anesthesiologist is recommended when airway obstruction is a possibility.

Diet
Diet modifications depend on the extent of surgery. After many oral surgical procedures, a liquid or
soft and bland diet is usually recommended for the first couple of days. More invasive surgeries that
involve the removal of a major salivary gland may require a modified diet for a longer period. Use of
tobacco products is not recommended until healing has occurred.

Activity
Depending on the extent of the procedure, strenuous physical and recreational activities are
discouraged for several days to several weeks after surgery.

Complications
A low risk of bleeding and low-to-moderate peripheral nerve damage exists after excision of a
mucocele.

No complications are associated with superficial mucoceles, unless the lesions are surgically excised.

Complications are more common with surgical intervention in oral and cervical ranulas than other
treatments. Possible surgical complications include the following: injury to the Wharton duct, leading to
stenosis, obstructive sialadenitis, and leakage of saliva; injury to the lingual nerve with temporary or
permanent paresthesia; and injury to the marginal mandibular branch of the facial nerve with
paresthesia. Postoperative hematoma, infection, or dehiscence of the wound may occur.

In addition, incomplete removal of the oral ranula increases the risk for developing a cervical ranula,
while a cervical ranula may extend into the mediastinum. Approximately 45% of plunging ranulas
occur after attempts to remove oral ranulas, which can result in a compromised airway. Cervical
ranulas can extend into the mediastinum and provoke a sterile mediastinitis that may be life
threatening.

The complications of a mucus retention cyst are the same as those for a mucus retention
phenomenon and an oral ranula, depending on the location.

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Prevention
Avoidance of local trauma to the minor salivary glands may help to prevent the development of oral
mucoceles. Although unanticipated injury to the mouth is difficult to predict, habits that irritate the
minor salivary glands such as sucking or chewing on the lips or tongue may be contributing factors.
Constant rubbing of the oral mucosa against sharp or fractured teeth or orthodontics appliances is a
potential cause. The discontinuation of contributing habits, restoration of damaged teeth, judicious use
of orthodontic wax with oral appliances, and wearing mouthguards in sports should be encouraged to
prevent oral irritations that could lead to the rupture and spillage of mucin into the surrounding
mucosa.

Superficial mucoceles can be prevented by treating the mucosal disease causing these lesions to
develop, including chronic mucocutaneous diseases and contact allergies. When xerostomia is a
contributing factor, recommend maintaining a moist oral environment through hydration and, if
necessary, oral moisturizers or lubricants.

Long-Term Monitoring
Mucus extravasation phenomenon
The recurrence rate of mucus extravasation phenomenon following surgical excision is low
(approximately 8%). [10] When micromarsupialization is performed, the recurrence rate after a short
follow-up period has been 14% in pediatric patients. [39] Continued irritation or trauma to the affected
tissues or incomplete removal of the feeder minor glands is the suspected causes of recurrences.

Superficial mucoceles

The recurrence rate for superficial mucoceles is high (approximately 50%), despite surgical removal.
Because these lesions are often multiple in number, the excised lesion may not represent a
recurrences but rather a new or undiagnosed concurrent lesion. To prevent recurrences when the
lesion is associated with an underlying mucocutaneous disease, management of the causative
disease is necessary.

Oral ranula
The recurrence rates of an oral ranula is variable depending on the size of the lesion and the surgical
procedure performed. The rates of recurrence with various surgical treatment methods are as follows
[48] :

Incision and drainage, 71-100%

Ranula excision only, 0-25%
Marsupialization only, 61-89%
Marsupialization with packing, 0-12% (limited studies)
Complete excision of the ranula with the sublingual gland, 0-2%

Cervical ranula

When the responsible major salivary gland is removed, the cervical ranula resolves and has a low risk
of recurrence. With drainage of the cervical ranula alone, the recurrence rate is greater than 85%.
When the sublingual gland is intraorally excised along with drainage of the cervical pseudocyst, no

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recurrences are observed. A cervical approach to excision of the neck pseudocyst and the sublingual
gland has a low recurrence rate (approximately 4%).

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Media Gallery

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15/1/2018 Mucocele and Ranula Treatment & Management: Approach Considerations, Medical Care, Surgical Care

Classic example of a mucocele in a child. The fluctuant, translucent-blue nodule on the lower
labial mucosa has been present for 6 weeks. Trauma from sucking on the lower lip was
suspected to be the cause.
Fluctuant submucosal nodule of the lower lip consistent with a mucocele.
Surgical excision of the mucocele in Media File 2.
Mucocele on the midline ventral surface of the tongue involving the glands of Blandin and Nuhn.
Example of 2 superficial mucoceles of the soft palate in a 50-year-old woman. The red lesion
represents a recently ruptured mucocele, and the translucent papular lesion represents an intact
mucocele.
Unilateral oral ranula in a young adult manifesting as a purple swelling.
Ranula on the floor of the mouth with focal ulceration.
Example of a cervical ranula with no oral involvement in an adult. The swelling developed after a
car accident in which the individual had trauma to the face and neck.
Low-power photomicrograph of a mucocele with attenuation of the mucosal surface and pooling
of mucus (hematoxylin-eosin, original magnification X40).
High-power photomicrograph of a mucocele with pooling of mucus and numerous foamy
histiocytes (hematoxylin-eosin, original magnification X400).
Intermediate-power photomicrograph of an affected minor salivary gland lobule with atrophy of
the acinar structures, ductal ectasia, and fibrosis (hematoxylin-eosin, original magnification
X100).

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Contributor Information and Disclosures

Author

Catherine M Flaitz, DDS, MS Professor and Chair, Division of Pediatric Dentistry, Chief of Dentistry,
Nationwide Children's Hospital

Catherine M Flaitz, DDS, MS is a member of the following medical societies: American Academy of
Oral and Maxillofacial Pathology, American Academy of Oral Medicine, American Academy of
Pediatric Dentistry, American Dental Association, American Dental Education Association,
International Association for Dental Research, International Association of Oral Pathologists

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for:
American Academy of Pediatric Dentistry Board of Trustees; Commissioner of Dental Accreditation;
Chief of Dentistry Nationwide Children's Hospital; Director, American Board of Ora and Maxillofacial
Pathology<br/>Serve(d) as a speaker or a member of a speakers bureau for: American Academy of
Pediatric Dentistry Speakers Bureau<br/>Received research grant from: Trimira LLC; GC America;
C3-Jian; others<br/>Travel Grant from GC America; American Academy of Pediatric Dentistry for
Continuing Education Presenter for: Multiple speaking engagements for dental meetings.

Coauthor(s)

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15/1/2018 Mucocele and Ranula Treatment & Management: Approach Considerations, Medical Care, Surgical Care

M John Hicks, DDS, MD, PhD, MS Professor with Tenure, Department of Pathology and
Immunology, Baylor College of Medicine; Medical Director of Ultrastructural Pathology, Department of
Pathology, Texas Children's Hospital; Professor of Pediatrics, Baylor College of Medicine; Adjunct
Professor, Department of Pediatric Dentistry, School of Dentistry, University of Texs Health Science
Center at Houston

M John Hicks, DDS, MD, PhD, MS is a member of the following medical societies: American Academy
of Oral and Maxillofacial Pathology, American Society for Clinical Pathology, College of American
Pathologists, International Academy of Pathology, International Association of Oral Pathologists

Disclosure: Nothing to disclose.

Specialty Editor Board

David F Butler, MD Section Chief of Dermatology, Central Texas Veterans Healthcare System;
Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of
Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: American Medical Association,
Alpha Omega Alpha, Association of Military Dermatologists, American Academy of Dermatology,
American Society for Dermatologic Surgery, American Society for MOHS Surgery, Phi Beta Kappa

Disclosure: Nothing to disclose.

Drore Eisen, MD, DDS Consulting Staff, Dermatology of Southwest Ohio

Drore Eisen, MD, DDS is a member of the following medical societies: American Academy of
Dermatology, American Academy of Oral Medicine, American Dental Association

Disclosure: Nothing to disclose.

Chief Editor

Jeff Burgess, DDS, MSD (Retired) Clinical Assistant Professor, Department of Oral Medicine,
University of Washington School of Dental Medicine; (Retired) Attending in Pain Center, University of
Washington Medical Center; (Retired) Private Practice in Hawaii and Washington; Director, Oral Care
Research Associates

Disclosure: Nothing to disclose.

Additional Contributors

Timothy McCalmont, MD Director, UCSF Dermatopathology Service, Professor of Clinical Pathology

and Dermatology, Departments of Pathology and Dermatology, University of California at San
Francisco; Editor-in-Chief, Journal of Cutaneous Pathology

Timothy McCalmont, MD is a member of the following medical societies: Alpha Omega Alpha,
American Medical Association, American Society of Dermatopathology, California Medical
Association, College of American Pathologists, United States and Canadian Academy of Pathology

Disclosure: Received consulting fee from Apsara for independent contractor.

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