Ranula: Symptoms, Types, Causes and Treatment

Ranula is an intriguing and somewhat rare condition that can present as a dramatic swelling in the floor of the mouth or even in the neck. Named after the Latin word for "frog" due to its resemblance to a frog's bulging underbelly, ranula is a type of mucocele (mucous cyst) that specifically arises from the sublingual gland or its ducts. Understanding ranula involves exploring its symptoms, types, underlying causes, and the most effective treatment options available today. Let’s dive deeper into what every patient—and healthcare provider—should know about this fascinating clinical entity.

Symptoms of Ranula

Ranula often makes its first impression with a characteristic swelling in the floor of the mouth, which can cause discomfort, interfere with eating, or, in the case of more extensive forms, present as a neck mass. Recognizing these symptoms early can help guide effective diagnosis and management.

Symptom	Location	Key Feature	Source(s)
Swelling	Floor/mouth	Bluish, fluctuant, painless mass	1 5 8
Neck swelling	Submandibular	May extend into neck (plunging)	3 5 8
Discomfort	Mouth/neck	May interfere with speech/eating	5 8
Recurrence	Mouth/neck	With incomplete treatment	1 11 12

Table 1: Key Symptoms

Swelling in the Floor of the Mouth

The hallmark of a simple ranula is a painless, bluish, and dome-shaped swelling on one side of the floor of the mouth. It is often soft, fluctuant, and can sometimes grow rapidly, causing notable discomfort or difficulty with speech and eating. In some cases, the swelling can even displace the tongue upwards, making daily activities challenging 1 5 8.

Plunging (Cervical) Swelling

If the ranula extends beyond the floor of the mouth through a defect in the mylohyoid muscle, it becomes a "plunging" or "diving" ranula. This variety presents as a soft, sometimes sizeable, swelling in the neck beneath the jawline (submandibular region), which may be the only visible symptom in certain cases 3 5 8. Importantly, these neck masses are often mistaken for other types of cysts or tumors, making accurate diagnosis essential.

Discomfort and Functional Impairment

While ranulas are typically painless, their location can cause significant discomfort. Patients might find it difficult to chew, swallow, or speak, especially when the swelling becomes large 5 8. In rare cases, if the mass is substantial, it can lead to airway compromise.

Recurrence

A notable symptom, particularly after suboptimal treatment, is recurrence of the swelling. Ranulas have a high risk of coming back if the underlying cause—usually the sublingual gland—is not addressed surgically 1 11 12.

Types of Ranula

Ranulas are not a one-size-fits-all disorder. They are classified based on their anatomical location and extent, each with distinct clinical features and implications for management.

Type	Location	Defining Feature	Source(s)
Oral (Simple)	Sublingual space	Confined to mouth floor	1 2 5 7
Plunging	Neck/submandibular	Extends beyond mouth floor	3 5 7 8
Mixed	Mouth + neck	Both oral and cervical swelling	1 7
Congenital	Mouth (babies)	Lined by epithelium (rare)	7

Table 2: Types of Ranula

Oral (Simple) Ranula

This is the most common type, characterized by a cystic lesion confined to the sublingual space in the floor of the mouth. Oral ranulas are often bluish and translucent, and they do not extend into the neck 1 2 5 7.

Plunging (Cervical) Ranula

Plunging ranulas develop when mucous escapes through a defect in the mylohyoid muscle, extending into the neck or submandibular region. Unlike oral ranulas, these can present as neck swellings without any oral findings, complicating the diagnosis 3 5 7 8.

• Anatomical Pathway: Most plunging ranulas propagate through an anterior defect in the mylohyoid muscle, allowing the sublingual gland or mucin to herniate and track into the neck spaces 3 5 7.

Mixed Ranula

Some patients present with both intraoral and cervical swelling, termed "mixed ranula." This reflects simultaneous involvement of the sublingual and cervical spaces 1 7.

Congenital Ranula

Rarely, ranulas can appear in newborns as congenital cysts lined with epithelium (retention cysts), differing from the classic extravasation pseudocyst seen in most cases 7.

Causes of Ranula

Understanding what triggers a ranula is key to both prevention and effective management. While the exact cause can vary, most ranulas result from trauma or ductal disruption, leading to mucous leakage.

Cause	Mechanism	Impact	Source(s)
Trauma	Duct rupture, leak	Mucous extravasation	5 6 7 8
Ductal obstruction/rupture	Blockage or injury	Saliva accumulation	5 6 7
Mylohyoid muscle defect	Anatomical dehiscence	Enables neck extension	3 5 6 7
Congenital anomaly	Developmental	Retention cyst formation	7
Sjögren’s syndrome (rare)	Inflammatory damage	May facilitate leakage	9

Table 3: Causes of Ranula

Traumatic Extravasation

The most widely accepted cause of ranula is mechanical trauma to the sublingual gland or its ducts. This can arise during everyday activities such as eating, dental work, or accidental injury. The trauma leads to rupture of the duct, causing mucous to leak into surrounding tissues and form a pseudocyst (a cyst without a true epithelial lining) 5 6 7 8.

Ductal Obstruction or Rupture

Obstruction of the sublingual gland duct—whether from trauma, inflammation, or a salivary stone—can increase intraductal pressure, contributing to rupture and subsequent mucous extravasation 5 6 7.

Mylohyoid Muscle Defect

An anatomical weakness or defect (dehiscence) in the mylohyoid muscle is a key factor in the development of plunging ranulas. This defect allows mucous or even part of the sublingual gland itself to herniate into the neck spaces, explaining why some ranulas extend below the jawline 3 5 6 7.

Congenital Anomalies

Rarely, congenital ranulas arise due to developmental anomalies, resulting in a true cyst lined with epithelium (retention cyst), rather than a pseudocyst 7.

Systemic Associations

Occasionally, systemic diseases like Sjögren’s syndrome, which involve chronic inflammation of the salivary glands, may predispose individuals to develop ranulas by damaging the salivary ducts 9. However, this is considered rare.

Treatment of Ranula

Treating ranula effectively requires a strategic approach tailored to the type and extent of the lesion. Modern management options range from minimally invasive procedures to definitive surgical interventions.

Treatment	Approach	Recurrence Rate	Source(s)
Marsupialization	Drain and suture open	High (>30-60%)	1 4 11 12
Excision of cyst only	Remove cyst	High (25-57%)	1 11 12
Sublingual gland excision	Remove gland (oral)	Low (~1-4%)	1 4 7 11 12
Transcervical gland excision	Remove gland (neck)	Low, more morbidity	4 7
Sclerotherapy	Induce fibrosis	Variable	4 10
Aspiration/incision & drain	Relieve pressure	Not recommended	8 10

Table 4: Treatment Options and Outcomes

Marsupialization

Marsupialization involves incising the ranula and suturing its wall to the oral mucosa, creating a permanent opening for drainage. While this method is simple and minimally invasive, it carries a high recurrence rate—ranging from 30% to over 60%—especially if the sublingual gland is not addressed 1 4 11 12.

Excision of the Ranula Only

Removing just the cystic lesion without excising the sublingual gland is associated with significant risk of recurrence (25-57%) 1 11 12. This is because the underlying gland continues to leak saliva, forming new cysts.

Sublingual Gland Excision

Complete removal of the sublingual gland, often via a transoral (intraoral) approach, is widely recognized as the gold standard treatment for both oral and plunging ranulas. This approach yields the lowest recurrence rates (1-4%) and minimizes complications when compared to transcervical approaches 1 4 7 11 12.

• Transoral vs. Transcervical: For plunging ranulas, both intraoral and transcervical gland excision are effective, but intraoral surgery typically results in fewer complications 4 7.

Sclerotherapy

Injection of sclerosing agents (such as OK-432) to induce fibrosis at the leakage site has shown some success, particularly in pediatric cases or when surgery is contraindicated. However, cure rates are inconsistent, and this is not considered first-line therapy 4 10.

Aspiration, Incision, and Drainage

Simple aspiration or incision and drainage may provide temporary relief but are not recommended as definitive treatments due to a near-universal risk of recurrence 8 10.

Minimally Invasive Alternatives

Micromarsupialization and laser excision have been explored as less invasive alternatives, especially in children. While some reports suggest reasonable outcomes, these methods require further robust study for widespread recommendation 4 10.

Diagnostic and Surgical Considerations

• Imaging: Ultrasound, CT, and MRI are valuable for distinguishing ranula from other cystic neck masses, particularly in identifying plunging ranulas and their anatomical relationships 2 3 12.
• Complications: Major complications from surgery are rare but may include nerve injury or hematoma, particularly with transcervical approaches 4 12.

Conclusion

Ranula is a unique salivary gland disorder that can have a significant impact on quality of life if not properly managed. Here’s a recap of what we’ve covered:

• Symptoms: Typically presents as a painless swelling in the floor of the mouth, with possible extension to the neck in plunging ranulas. Discomfort and recurrence are key concerns 1 5 8 11 12.
• Types: Includes oral (simple), plunging (cervical), mixed, and rare congenital forms—each with distinct clinical and anatomical features 1 2 3 5 7 8.
• Causes: Most commonly due to trauma or ductal rupture in the sublingual gland, with defects in the mylohyoid muscle facilitating neck extension; rare systemic associations exist 3 5 6 7 8 9.
• Treatment: The gold standard is complete excision of the sublingual gland, best performed via an intraoral approach for both oral and plunging ranulas due to low recurrence and fewer complications. Marsupialization and other less invasive options may be considered in select cases, particularly in children, but have higher recurrence rates 1 4 7 11 12.

Key Takeaways:

• Prompt recognition and appropriate imaging are crucial for diagnosis.
• Definitive surgical management offers the best long-term outcomes.
• Recurrence is common with incomplete treatment—addressing the sublingual gland is essential.
• Less invasive treatments may be appropriate for select patients but require close follow-up.

If you or someone you know experiences persistent swelling in the mouth or neck, consult a healthcare professional for proper assessment and management—early intervention can make all the difference.