see detailed images and description: Plunging Ranula Transoral Resection (Sublingual Gland) Aided With Sialendoscopy with Histopathology

Sublingual gland salivary stones (sialolithiasis) transoral resection technique / Floor of Mouth Anatomy - Bartholin's Duct, Wharton's Duct, Sublingual Gland, Lingual Nerve, Uncinate Process

Content compiled by Evgeniya Molotkova, BS (3/18/2025)

Definitions

Ranula – derived from the Latin word “rana” (frog), and is defined as a mucous extravasation pseudocyst that forms due to trauma or obstruction of the sublingual gland duct (Packiri et al, 2017)(Bachesk et al, 2021) 

• Cyst: collection of fluid material that is lined by a layer of epithelial cells (Wikipedia contributors, 2024) 
• Pseudocyst: self-contained collection of fluid that does not have an inner epithelial cell lining, but is instead lined by fibrous or granulation tissue (Wikipedia contributors, 2024) 

Ranulas can be divided into two broad classes: 

• Oral (aka enoral or simple) ranula – extravasation pseudocyst of the sublingual gland that is contained to the floor of mouth (Bachesk et al, 2021) 
  • Presents clinically as a cyst or bubble-like mass in the floor of mouth 
• Plunging (aka diving, cervical, or complicated) ranula – an extravasation pseudocyst of the sublingual gland that herniates through a defect in the mylohyoid muscle or around the mylohyoid muscle that may extend into the parapharyngeal space (Bachesk et al, 2021) 
  • Presents clinically as an isolated neck mass, although it may also have an oral component 

Other fluid containing structures of the oral cavity include 

• Mucocele: lesion resulting from a salivary duct rupture with extravasation (spillage) of mucus into the surrounding connective tissue without an epithelial lining (Chi 2010) 
  • Mucoceles represent a "mucus escape reaction" and "mucus extravasation phenomenon"  
• Mucus retention cyst (also known as a sialocyst or mucus duct cyst) are cysts lined by salivary ductal epithelium (Chi 2010) 
  • Mucus retention cysts develop from mucus buildup behind blocked glandular ducts - more commonly in cheek (buccal) or palate areas (Bowers 2021) 

 

Background

Oral ranula typically presents in the first two decades of life whereas plunging ranula more commonly presents later in life, around the third decade. With both types of ranula, females are affected more frequently compared to males (Packiri et al, 2017) (Bachesk et al, 2021). 

Risk factors for the development of ranula have been reported to include trauma or obstruction to sublingual gland drainage.  Mun and colleagues found that ranulas were more commonly found in patients with a Bartholin’s duct that emptied into Wharton’s duct (Mun et al, 2013). Ranulas are rare in children, with the prevalence of congenital ranula (due to underlying anatomic predisposition) is less than 1% (Packiri et al, 2017). If left untreated, ranula may cause difficulty with speech and mastication. Case studies have documented the rare complication of ranula causing acute airway obstruction (Clyburn et al, 2009). 

The surgical approach to a ranula may be individualized but often includes removal of the sublingual gland (Bachesk et al, 2021). Partial excision of a plunging ranula may increase the risk of recurrence with current recommendations supporting total sublingual gland resection. Removal of the ranula without removing the sublingual gland has high rates of recurrence and are not preferred in most cases (Mahadevan et al, 2006). Generally, the preferred surgical approach to plunging ranula is excision of the sublingual gland. Historically, the cervical approach was favored but has been supplanted by the transoral approach (Patel et al, 2009)(Lesperance et al, 2013).  

Treatment approaches warrant assessment of the ranula’s extent (oral or plunging). A meta-analysis by Lazzeroni and colleagues found that the full spectrum of treatment (from minimally invasive treatments to sialectomy) were marginally more effective in managing oral ranulas. Reported success with this limited approach identifies value for less invasive treatment to manage small, simple ranula (Lazzeroni et al, 2024). Sigismund and colleagues found that whereas total sublingual gland excision is the preferred treatment modality for both simple and complex ranulas, marsupialization (effective in 85% of cases) can be considered as an alternative in patients who would prefer a minimally invasive procedure (Sigismund et al, 2013). Zhi and colleagues recommended that simple ranulas in infants should be treated initially with aspiration and observation for recurrence. If a ranula recurs, sublingual gland excision is suggested at or after 1 year of age (Zhi et al, 2008). 

 

Evaluation

Historically, ranulas are initially assessed by computed tomography (CT) or magnetic resonance imaging (MRI). The “tail sign,” defined as a smooth tract that extends from the lesion at the posterior edge of the mylohyoid muscle anteriorly into the sublingual space, is pathognomonic for a plunging ranula (Yun et al, 2024). However, this ‘tail sign’ finding is not always present. In a study by Jain, only 2 out of 126 patients with plunging ranula displayed the tail sign on ultrasound (Jain, 2020). CT and MRI do not always accurately identify ranula as identified by Yun and colleagues demonstrating that the two modalities have a 73% and 71% success rate (Yun et al, 2024) 

Ultrasound has been increasingly utilized to diagnose both simple and plunging ranula. This technique is especially useful in pediatric populations, as it delivers less radiation than CT and can be performed faster, without the need for consequent sedation as is commonly needed in this age group to perform MRIs (Jain et al, 2012).  

Dynamic imaging with ultrasound can also be useful in the diagnosis of ranula. Ultrasound can allow for improved visualization of a dehiscence in the mylohyoid, especially useful for the accurate diagnosis of plunging ranula (Jain et al, 2010). While ultrasound is useful, it has limited ability to visualize the intraoral components of a ranula (Yun et al, 2024). This shortcoming can be addressed by the use of sonopalpation, a technique where the ultrasound operator uses their gloved hand to manually depress intraoral tissues closer to the ultrasound transducer. 

 

Consent for Surgery

Patients should be adequately counseled on both the benefits and risks of enoral sublingual gland excision. The benefit of surgery to remove a ranula would be reduction in or cessation of symptoms associated with it (i.e. bothersome oral or neck mass, difficulties with speaking/chewing, etc.). Important risks to discuss include: 

• Recurrence 
  • The risk of recurrence is lowest with enoral excision of the sublingual gland and ranula evacuation 
    • Studies have suggested that the risk of ranula recurrence with this technique is approximately 1 % (Zhao et al, 2005) 
• Lingual nerve injury (5% risk)(Zhao et al, 2005) 
  • The lingual nerve passes near the submandibular duct and mylohyoid muscles, which makes it a structure that could be damaged. Damage to the lingual nerve may cause temporary or permanent (depending on degree of damage) tongue numbness or change in taste (Fagan et al, 2025). 
• Injury to Wharton’s duct (1-2% risk)(Zhao et al, 2005)  
  • May cause interruption to the transport of saliva from the submandibular gland into the mouth. May present with symptoms of obstructive sialadenitis, such as pain and swelling (Lazaridou et al, 2012) 
    • Typically mitigated by intraoperative cannulation of the duct with a lacrimal probe or catheter (Zhao et al, 2005) 
• Tongue tethering 
  • Scar formation from incisions may cause tongue tethering that interferes with speaking, swallowing, and chewing 
• Bleeding and hematoma formation 
  • In severe cases, acute bleeding and hematoma may cause acute airway compromise 
• Infection and wound dehiscence  
  • May cause pain and delayed wound closure/overall recovery course 

 

Preoperative Considerations

1. Anti-staphylococcal antibiotic (ie unasyn or the equivalent) should be administered on induction..
2. The oral endotracheal tube should be taped in such a fashion that the lesion side of the mouth is readily accessible. Alternatively transnasal intubation.
3. The patient should be prepped and draped in the usual fashion for intra-oral procedure.

 

Nursing Considerations

 

Anesthesia Considerations

 

Operative Procedure

1. Place a Molt mandibular retractor or a black bite block to gain adequate visualization of the floor of mouth and sub-lingual gland.
2. Have your assistant use Wieder or Minnesota retractors to retract the lips and gingivo-buccal mucosa.
3. for detail see: Plunging Ranula Transoral Resection (Sublingual Gland) Aided With Sialendoscopy with Histopathology and Sublingual gland salivary stones (sialolithiasis) transoral resection technique

 

Sublingual Gland Attachments

POSITION	ATTACHMENT
Superior	Floor of mouth mucosa
Medial	Wharton’s duct and tongue musculature
Antero-medial	The lingual nerve
Inferior	Mylohyoid muscle
Posterior	lingual nerve runs underneath Wharton’s duct posteriorly creating an ‘X’
Deep and posterior:	Mandible and the submandibular gland

 

References

Packiri S, Gurunathan D, Selvarasu K. Management of Paediatric Oral Ranula: A Systematic Review. J Clin Diagn Res. 2017 Sep;11(9):ZE06-ZE09. doi: 10.7860/JCDR/2017/28498.10622. Epub 2017 Sep 1. PMID: 29207849; PMCID: PMC5713871. 

Wikipedia contributors. (2024, August 25). Pseudocyst. In Wikipedia, The Free Encyclopedia. Retrieved 21:16, February 10, 2025, from https://en.wikipedia.org/w/index.php?title=Pseudocyst&oldid=1242146377 

Bachesk AB, Bin LR, Iwaki IV, Iwaki Filho L. Ranula in children: Retrospective study of 25 years and literature review of the plunging variable. International Journal of Pediatric Otorhinolaryngology. 2021/09/01/ 2021;148:110810. doi:https://doi.org/10.1016/j.ijporl.2021.110810 

Mun SJ, Choi HG, Kim H, et al. Ductal variation of the sublingual gland: A predisposing factor for ranula formation. Head & Neck. 2014;36(4):540-544. doi:https://doi.org/10.1002/hed.23324 

Clyburn, V. L., Smith, J. E., Rumboldt, T., Matheus, M. G., & Day, T. A. (2009). Ascending and plunging ranula in a pediatric patient. Otolaryngology-Head & Neck Surgery, 140(6). 

Mahadevan M, Vasan N. Management of pediatric plunging ranula. International Journal of Pediatric Otorhinolaryngology. 2006/06/01/ 2006;70(6):1049-1054. doi:https://doi.org/10.1016/j.ijporl.2005.10.022 

Patel MR, Deal AM, Shockley WW. Oral and plunging ranulas: What is the most effective treatment? The Laryngoscope. 2009;119(8):1501-1509. doi:https://doi.org/10.1002/lary.20291 

Lesperance MM: When Do Ranulas Require a Cervical Approach? Laryngoscope 2013 Aug; 123  pp 1826-1827 

Yun J, Gidumal S, Saturno MP, et al. Diagnostic Difficulties of Plunging Ranula: A Review of 18 Cases. The Laryngoscope. 2024;134(6):2689-2696. doi:https://doi.org/10.1002/lary.31288 

Jain P. Plunging Ranulas and Prevalence of the “Tail Sign” in 126 Consecutive Cases. Journal of Ultrasound in Medicine. 2020;39(2):273-278. doi:https://doi.org/10.1002/jum.15100 

Jain R, Morton RP, Ahmad Z. Diagnostic difficulties of plunging ranula: case series. The Journal of Laryngology & Otology. 2012;126(5):506-510. doi:10.1017/S0022215112000230 

Jain, P., Jain, R., Morton, R.P. et al. Plunging ranulas: high-resolution ultrasound for diagnosis and surgical management. Eur Radiol 20, 1442–1449 (2010). https://doi.org/10.1007/s00330-009-1666-1 

Lazzeroni M, Del Fabbro M, Gaffuri M, et al. Sublingual ranulas, is it time for a new classification? A systematic review and meta-analysis. The Journal of Laryngology & Otology. 2024:1-7. doi:10.1017/S0022215124001464 

Gontarz M, Bargiel J, Gąsiorowski K, et al. Surgical Treatment of Sublingual Gland Ranulas. Int Arch Otorhinolaryngol. Apr 2023;27(2):e296-e301. doi:10.1055/s-0042-1744166 

Zhi K, Wen Y, Ren W, Zhang Y. Management of infant ranula. Int J Pediatr Otorhinolaryngol. 2008;72(06):823–826. doi: 10.1016/j.ijporl.2008.02.012 

Fagan SE, Roy W. Anatomy, Head and Neck, Lingual Nerve. [Updated 2023 May 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK546652/ 

Lazaridou M, Iliopoulos C, Antoniades K, Tilaveridis I, Dimitrakopoulos I, Lazaridis N. Salivary gland trauma: a review of diagnosis and treatment. Craniomaxillofac Trauma Reconstr. Dec 2012;5(4):189-96. doi:10.1055/s-0032-1313356 

Zhao Y-F, Jia J, Jia Y. Complications associated with surgical management of ranulas. Journal of Oral and Maxillofacial Surgery. 2005/01/01/ 2005;63(1):51-54. doi:https://doi.org/10.1016/j.joms.2004.02.018 

Chi AC, Lambert PR 3rd, Richardson MS, Neville BW. Oral mucoceles: a clinicopathologic review of 1,824 cases, including unusual variants. J Oral Maxillofac Surg. 2011 Apr;69(4):1086-93. doi: 10.1016/j.joms.2010.02.052. Epub 2010 Aug 12. PMID: 20708324. 

Miranda GGB, Chaves-Junior SC, Lopes MP, Rocha TBD, Colares DF, Ito FA, Cavalcante IL, Cavalcante RB, Andrade BAB, Nonaka CFW, Alves PM, Albuquerque-Júnior RLC, Cunha JLS. Oral mucoceles: A Brazillian Multicenter Study of 1,901 Cases. Braz Dent J. 2022 Sep-Oct;33(5):81-90. doi: 10.1590/0103-6440202204965. PMID: 36287502; PMCID: PMC9645162. 

Bowers EMR, Schaitkin B. Management of Mucoceles, Sialoceles, and Ranulas. Otolaryngol Clin North Am. 2021 Jun;54(3):543-551. doi: 10.1016/j.otc.2021.03.002. PMID: 34024482. 

Sigismund PE, Bozzato A, Schumann M, Koch M, Iro H, Zenk J. Management of Ranula: 9 Years' Clinical Experience in Pediatric and Adult Patients. Journal of Oral and Maxillofacial Surgery. 2013/03/01/ 2013;71(3):538-544. doi:https://doi.org/10.1016/j.joms.2012.07.042