A ranula is a cystic lesion on the floor of the mouth, usually resulting from an obstructed salivary gland duct. The lesion appears as a blue, translucent swelling and emanates mucus on aspiration. A ranula is usually a retention pseudocyst that forms due to a leak of mucus from the sublingual gland as a result of trauma, mucous extravasation, or duct obstruction. A plunging or diving ranula arises in the mouth and winds its way into the neck. Ranulas are usually diagnosed with physical examination, although imaging may be indicated to confirm the diagnosis. If indicated, ranulas can be treated with simple excision, marsupialization, or, if surgically significant, sclerotherapy.
A ranula is a mucus-filled cystic lesion on the floor of the mouth that represents a dilated salivary duct. It appears as a bluish swelling and can either be localized (simple ranula) or extend into the neck (plunging ranula). Treatment options depend on the size and type of the lesion.
A ranula develops when mucus builds up as a result of an obstruction in a salivary gland's drainage, especially the sublingual gland, which is situated behind the tongue. Among the primary causative factors are:
- Trauma: Any injury to the floor of the mouth can result in ductal damage, causing mucus to accumulate and form a cyst.
- Mucous extravasation phenomenon: Refers to the escape of mucus into the surrounding tissues when the salivary gland duct is ruptured.
- Ductal obstruction: When the opening of the salivary duct into the floor of the mouth becomes blocked with either a salivary stone (sialolith) or for other reasons, mucus may pool leading to the formation of a cyst.
- Congenital factors: The congenital presence of a ranula from birth is rare. If present, it may probably represent the failure of the development of the salivary duct system.
Here are the typical symptoms connected with a ranula:
- Visible swelling: The most obvious sign of a ranula is a soft, usually bluish, transparent swelling on the floor of the mouth. This swelling sometimes may be painful.
- Size of the lump may vary: The size of the ranula lump can change. The lump is usually larger after eating because being active stimulates more saliva secretion. The lump may shrink as some of the fluid is reabsorbed or drains.
- Discomfort or pain: The swelling caused by a ranula can make speaking, eating, and moving the tongue uncomfortable or mildly painful, depending on the extent of the swelling and its location within the mouth.
- Difficulty eating or speaking: A large ranula can extend into tongue movements, making it difficult to eat or talk.
- Plunging ranula: In some rare cases, a ranula can extend through the floor of the mouth and into the neck (plunging ranula), causing other signs and symptoms, such as swelling and pain in the neck.
- Asymptomatic: Occasionally, a small ranula that's discovered incidentally during a dental exam or other procedure causes no signs or symptoms.
The clinical examination and patient history are often used to make the diagnosis of a ranula. A ranula is often identified as follows:
- Clinical examination: The mainstay of diagnosing a ranula is a thorough clinical examination of the oral cavity; the characteristic bluish, translucent swelling on the floor of the mouth, usually beneath the tongue, is its main characteristic.
- History: Ask about duration since onset, activities, incidents of traumatic injury, and the time and circumstances under which the swelling has waxed and waned.
- Ultrasound: For plunging ranulas, an ultrasound is used to evaluate the cystic structure, its size, and the extent of the cyst; one valuable aspect is to delineate the exact capsule limits superiorly which may be the neck structure just below the tongue base.
- Magnetic resonance imaging (MRI) or computed tomography (CT) scan: When the diagnosis is in doubt or in the situation of a falling ranula, an MRI or CT scan is recommended to evaluate the details of the lesion and its relationship to the surrounding structures.
- Fine Needle Aspiration (FNA): A fine needle is placed into the swelling if there is any doubt about the diagnosis and if RDCM is considered a possibility. Aspiration of thick, clear mucus supports the diagnosis of a ranula.
- Histopathological Examination: In very rare instances, if there is doubt about the exact nature of the lesion, a biopsy might be necessary and the specimen sent to a pathologist for microscopic examination.
Depending on their size, location, and whether they are simple or plunging, ranulas require different treatments. The most typical ranula treatments are listed below:
- Observation: Some small ranulas that are asymptomatic can then be observed without further intervention because spontaneous resolution can occur.
- Marsupialization: Surgical marsupialization involves making a small incision or opening into the ranula to allow the mucus to drain. The edges of the cyst formed are then sewn to the lining of the mouth or neck so that a permanent opening is maintained, which prevents the ranula from recurring. This is most effective for smaller ranulas.
- Sclerotherapy: Sclerotherapy involves injecting a sclerosing agent, such as OK-432 or doxycycline, into the ranula. The agent causes inflammation, resulting in shrinkage and scarring of the ranula. This can be less invasive than surgery but may require multiple treatments that can last around 4 to 8 weeks.
- Surgical Excision: In some cases where the ranula is large or has come back after prior treatments, complete surgical removal may be recommended. This involves complete excision (removal) of the ranula and a portion of the salivary gland to help prevent reoccurrence.
- Removal of the Ranula with Excision of the Gland: The most definitive treatment of ranula, particularly in recurrent or large ranulas, is the complete removal of the sublingual gland from which the cyst originated.
- Laser treatment: Some clinicians advocate puncturing the ranula with lasers to drain its contents and cause it to shrink. Although this treatment is typically less invasive than open surgery, skill and expertise are necessary to generate a full-thickness puncture of the ranula.
While many ranulas may be adequately treated without developing long-term problems, sometimes the ranula or the therapy might cause difficulties. The following are possible issues related to ranulas:
- Recurrence: One of the most common complications of the ranula surgery is a recurrence of the ranula. This may happen if the ranula is not completely removed or if the underlying cause (such as a salivary duct obstruction) is not treated.
- Infection: Rarely, a ranula may become infected. Signs of infection include increased pain, swelling, redness or warmth, or purulent drainage from the site.
- Hematoma: After surgery, bleeding may occur, causing the formation of a hematoma, or a localized collection of blood.
- Scarring: Scarring may develop after surgical treatment in the area where the ranula was removed.
- Nerve damage: Many nerves run through the floor of the mouth and surrounding areas. Surgery in this region carries the risk of damage to these nerves, which may result in numbness or altered sensation.
- Damage to Surrounding Structures: There is a risk of injury to other salivary glands, blood vessels, or muscles, particularly with surgical treatments or with the removal of a plunging ranula.Complications of Sclerotherapy: There is a risk of local reaction or complications from the injection of sclerosing agents, including pain, swelling, and allergies.
Ranulas develop when salivary ducts get blocked or burst, frequently as a result of trauma or other unidentified causes. Although not all ranulas may be avoided, the following basic precautions may help lower the risk:
- Prevent oral trauma: Reducing trauma to the floor of your mouth can help prevent ranula. This may include being careful with sharp food items or utensils, wearing a mouth guard while participating in contact sports, and not getting pierced in your lip or tongue, since this may cause injury.
- Oral hygiene: Keeping your mouth clean may decrease the chance of a blocked or infected duct that may cause a ranula. Regular visits to the dentist or dental hygienist may also help find and fix oral problems early.
- Stay hydrated: Drinking enough water will help make sure that your saliva stays thin and runny, which may decrease the chance of a blockage.
- Avoid any medicine that dehydrates: If you’re able to, avoid any medicine that makes your mouth dry, or causes thick saliva that may contribute to a blockage.
- Regular check-ups: Regular visits to the dentist allow them to catch any oral issues, such as a small injury or a sore, that may make a ranula more likely to develop.
- Do not make excessive mouth movements: Any repetitive or exaggerated mouth movements or habits that keep potential gum line swelling are hazardous. For example, perpetual chewing of gum could conceivably increment an individual's odds of damage to the salivary conduits.
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