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Plunging Ranula

Cervical mucus extravasation pseudocyst arising from the sublingual gland that 'plunges' through or around the mylohyoid muscle into the submandibular and parapharyngeal spaces, presenting as a soft, non-tender neck swelling.

Written by: Saygı Hospital Health Guide Editorial Board
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This content is for general information; please consult your physician for diagnosis and treatment.

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What is Plunging Ranula?

A plunging ranula is a mucus extravasation pseudocyst (it lacks a true epithelial lining) originating from a damaged or obstructed sublingual gland duct (Bartholin or Rivinus). Saliva escapes into the floor of the mouth submucosa and dissects inferiorly through a congenital or acquired mylohyoid muscle dehiscence (present in ~ 45% of population) into the submandibular space, parapharyngeal or even mediastinal spaces.

Pathophysiology distinguishes simple oral ranula (sublingual swelling only) from plunging ranula (cervical extension with or without oral component). The pseudocyst contains thick mucinous saliva rich in amylase (> 1000 U/L) and lined by granulation tissue, which differentiates it from a true cyst (lymphangioma, dermoid, branchial cleft cyst).

Definitive management is transoral sublingual gland excision with cyst evacuation through the mouth (Crysdale technique), which addresses the source and produces recurrence rates < 5%. Marsupialization or simple drainage have unacceptably high recurrence (50–90%). OK-432 (picibanil) sclerotherapy or botulinum toxin injection may be considered in poor surgical candidates.

Symptoms

Soft, painless, fluctuant submandibular or upper neck swelling
Bluish translucent swelling on floor of mouth (oral component)
Slow growth over weeks-months, transient enlargement after meals
Dysphagia, snoring or airway obstruction in large lesions
Cosmetic neck deformity
Spontaneous drainage of clear/mucoid fluid
Pain only if secondary infection develops

Risk Factors

Mylohyoid muscle dehiscence (anatomical predisposition)
Prior trauma to floor of mouth or sublingual gland
Sublingual sialolith causing ductal obstruction
Previous floor-of-mouth surgery or biopsy
Pacific Islander, Maori or Native American descent (higher prevalence)
Female sex (slight predominance) and age 10–30 years
Recurrent oral ranula treated with marsupialization only

When to See a Doctor?

If you experience any of the following symptoms, seek medical attention promptly:

  • Painless, slowly enlarging neck mass
  • Recurrence after previous ranula surgery
  • Acute swelling with pain or fever (infected ranula)
  • Difficulty swallowing or breathing
  • Sudden voice change or globus sensation
  • Cosmetic concern about neck swelling
  • Mass that fluctuates with meals

Treatment Methods

01
Diagnostic imaging: high-resolution ultrasound (cystic mass with comet-tail through mylohyoid), contrast MRI (T2 hyperintense 'tail sign'), CT for surgical planning
02
Fine-needle aspiration: viscous mucoid fluid with high amylase (> 1000 U/L) confirms diagnosis
03
Transoral sublingual gland excision with cyst evacuation (Crysdale technique) — gold standard, < 5% recurrence
04
Identification and protection of Wharton duct, lingual nerve and lingual artery during dissection
05
Avoidance of marsupialization or simple drainage (50–90% recurrence)
06
OK-432 (picibanil) intracystic sclerotherapy as alternative — 50–70% success in selected cases
07
Postoperative care: soft diet 1 week, oral hygiene with chlorhexidine rinses, avoidance of floor-of-mouth trauma

Which Department to Visit?

You can visit our KBB (Kulak Burun Boğaz) department for these complaints. Our specialist physicians will create the most suitable treatment plan for you.

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