Ranula/Mucocele

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The most common location for a mucocele is by far the lower lip. In the area of the tongue and floor of mouth (FOM), ranulas are unlikely to occur in the posterior tongue. The anterior FOM and ventral tongue are the most common locations for a ranula/mucocele in this area. However, the soft consistency of the swelling suggests this condition. The histology in this case is not supportive of a ranula/mucocele.

Mucoceles and ranulas are clinical terms describing exophytic, fluid-filled, fluctuant nodules, typically of minor salivary gland origin and present mostly on the lower lip and the floor of mouth. Over 90% of these lesions are cyst-like structures, or pseudocysts, and are mucous extravasation phenomena referred to as mucoceles. Some of these lesions are true cystic structures lined by epithelium and filled with mucus and are called mucus retention cysts or salivary duct cysts. These constitute a small percentage of all mucoceles. Ranulas, mucoceles of the floor of mouth, constitute another 5% of these lesions. They are divided into types by location of occurrence: those above the mylohyoid muscle, which make up the majority of cases, and those below the mylohyoid muscle (also known as plunging ranulas or cervical ranulas). Ranulas are of minor or major salivary gland origin and are mostly extravasation in type. The etiology of extravasation mucoceles is usually sharp trauma cutting through the salivary gland duct and releasing the mucous in the extracellular tissue. Histologically, the extravasation-type mucocele consists of a cyst-like structure lined by granulation tissue and filled with mucoid material, foamy macrophages, and at times small clusters of neutrophils. The mucous retention cysts develop as a result of a duct blockage which can be caused by trauma, fibrosis, sialolith, or pressure from an overlying tumor. Extravasation mucoceles most commonly occur on the lower lip and very rarely on upper lip. They may occur anywhere else in the oral cavity, including the buccal mucosa and floor of mouth (Ranula). The latter can be of minor salivary gland or submandibular or sublingual gland duct origin and is more commonly seen in children and adolescents. It presents as a swelling with a bluish color if superficial, while deep mucoceles tend to take the color of the surrounding mucosa. Mucoceles tend to fluctuate in size. They are usually associated with a history of sharp lip or cheek biting, but can also be secondary to surgery in the area. This is especially true with the anterior tongue mucoceles. Surgical excision with the associated minor salivary gland is the preferred treatment for deep mucoceles; superficial mucoceles can self-heal within 2-3 weeks. Superficial mucoceles can also mimic vesiculobullous-type diseases because they look like vesicles, especially when presenting in multiples (an occurrence that is rare, but described in the literature). They can recur if the source of trauma is not eliminated or if they are secondary to surgery. Simple (non-plunging) ranula is best treated by marsupialization into the floor of mouth. Plunging ranula requires complete excision via an extra-oral approach. The technical difficulties associated with the complete removal of this thin-walled lesion result in a relatively high recurrence rate.