Fine needle aspiration (FNA) is routinely used by some authors for diagnosis of ranulas based on aspiration of mucous, presence of amylase in the fluid, and/or cytology consistent with inflammation. However, FNA under local anesthesia may not be well tolerated by children. Imaging is not uniformly necessary, but it may be useful to confirm diagnosis. With ultrasound, ranulas appear as hypoechoic cystic masses with internal echoes. For plunging ranulas, a dehiscence in the mylohyoid muscle is characteristically observed. For recurrent lesions or plunging ranulas, computed tomography or magnetic resonance imaging may be helpful to localize the lesion and exclude other etiologies. However, imaging may not always give a definitive diagnosis. For example, lesions such as dermoid cysts may also appear as well-circumscribed, low attenuation masses.
Intraoral treatment options for ranulas include simple incision and drainage, marsupialization, excision of the ranula with or without excision of the sublingual gland, or excision of the sublingual gland with “evacuation” of a plunging ranula. External cervical approaches include needle aspiration of the cervical component, excision of the submandibular gland, excision of the pseudocyst, or external incision and drain placement, all of which may be combined with intraoral approaches. Use of OK-432, various lasers, and robotic surgery have also been reported. Many case series are small; and many reports combine pediatric and adult cases, intraoral and plunging ranulas, primary and recurrent cases, and a variety of surgical approaches, contributing to a lack of clarity in the literature.
Intraoral excision of the ipsilateral sublingual gland is recommended for most ranulas. Plunging ranulas may be amenable to the evacuation of contents through the intraoral incision, but in revision cases or large pseudocysts a cervical incision is advised to confirm diagnosis, and to allow placement of a drain through the neck with application of a neck pressure dressing. Complete excision of the pseudocyst wall is not necessary (Laryngoscope. 2013;123:1826-1827).