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Mucoceles
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Oral mucoceles fall into two categories: the mucous extravasation cyst and the mucous retention cyst. The mucous extravasation cyst describes a false cyst because the mucous extravasation cyst lacks an epithelial lining arising from the partially or totally severed salivary gland duct, resulting in the accumulation of saliva in the adjacent soft tissue. At this point, the mucocele is cut off by a fibrous connective tissue pseudocapsule. Ductal epithelium lines the mucous retention cyst. The mucous retention cyst develops from partial obstruction of a duct in the presence of the salivary gland’s continued mucus secretion. The extravasation mucocele manifests most commonly, and on the young person’s lower lip. The retention mucocele is more likely to occur on the buccal cheek or soft palate of an older patient. Despite differences in etiology, extravasation mucoceles and retention mucoceles tend to respond similarly to treatment.
Mucous extravasation cysts arise from trauma to salivary gland ducts. This trauma leads to the rupture of ducts and leakage of mucin from the minor salivary glands. The mucin subsequently forms pseudocystic aggregations, most commonly on the lower lip. These aggregations are referred to as mucoceles . Mucoceles manifest with a variety of tones and colors ranging from flesh to red to translucent blue. The shape of mucoceles is round or oval, and their surface is smooth. They usually possess a soft, fluctuant, or gel-like consistency. Single or multiple mucoceles can manifest and can range from 0.1 to 2 cm in diameter. A variant of a mucocele termed superficial mucocele can manifest on the palate, retromolar pad, and posterior buccal mucosa as single or multiple vesicles, which can ulcerate. Despite healing after a few days, superficial mucoceles often recur in the same location. A mucocele is termed a ranula when on the floor of the mouth, and an epulis when on the gums.
Management Strategy
The natural history of mucoceles can involve their expansion and periodic rupture, and sometimes spontaneous resolution. For small, superficial mucoceles clinicians may opt to just observe the lesions, as they often resolve without treatment. There is some morbidity associated with mucoceles ranging from discomfort to suboptimal cosmetic appearance of a nodule with a hardened consistency due to scarring and tissue consolidation.
A clinical diagnosis can be supported, when necessary, by histology, ultrasound imaging, and mucoscopy. Providers should consider human immunodeficiency virus (HIV) testing in at-risk patients as both simple and plunging type ranula are more common in HIV-positive patients.
A range of surgical and other techniques can be employed for the treatment of mucoceles. First-line therapies include cryotherapy, intralesional corticosteroids, and sclerotherapy; these procedures are minimally invasive, cause minimal discomfort, and have high clinical success rates. However, these therapies often require multiple treatments to completely clear the lesion. Punch biopsy may be considered as second-line therapy for small mucoceles on the buccal mucosa, labial mucosa, floor of the mouth, anterior one-third of the tongue, and gingiva. It has the added benefit of confirming the diagnosis on histology, but there is an increased risk of scarring, swelling, and bleeding. Third-line therapies include CO 2 and non-ablative lasers, surgical excision, marsupialization, and microwave ablation. These therapies have high clinical success rates but are significantly more expensive and result in higher morbidity than first- and second-line therapies. Microwave ablation, micromarsupialization, and laser treatments are less invasive and more efficient than surgical excision, and thus may be more suitable for children or patients who cannot tolerate long procedures. Recurrence rates are similar between surgical excision and laser treatments; however, there is limited data on recurrence among other treatment modalities. Recurrence is higher in younger patients and lesions located on the ventral surface of the tongue – clinicians may consider close follow-up in these cases.
Specific Investigations
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Biopsy
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Doppler ultrasonography
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Color Doppler imaging
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Mucoscopy
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HIV testing
Mucoscopy of mucocele
Kaur I, Jakhar D, Anand P. Indian Dermatol Online J 2019; 10: 358–9.
Dermoscopy of mucoceles reveals a shiny surface, with an extensive network of linear and branched vessels and intervening white structureless areas. In comparison, mucoscopy of healthy mucosa reveals linear and serpentine vessels and the absence of white structureless areas.
Oral mucocele/ranula: Another human immunodeficiency virus-related salivary gland disease?
Syebele K, Munzhelele T. Laryngoscope 2015; 125: 1130–6.
HIV-positive patients are significantly more likely to present with simple and plunging type ranula compared with uninfected patients.
The efficacy of polidocanol sclerotherapy in mucocele of the minor salivary gland
Liu J, Zhang A, Jiang L, et al. J Oral Pathol Med 2018; 47: 895–9.
In this study, 122 cases of mucocele of the minor salivary gland were treated with polidocanol sclerotherapy. Of these, 102 cases were cured and 10 had partial remission, resulting in a total cure rate of 91.07%. There were no recurrences and no severe side effects during or after treatment. Treatment of mucoceles on the lower lip was more successful than on the inferior surface of the lingual apex.
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