If ectopic sublingual gland is present on the cervical surface of the mylohyoid, this may be missed without exploring the undersurface of the muscle. Some surgeons advocate simply draining the cervical portion of the ranula and excising the gland transorally. Complete excision of the cyst is not necessary if the gland itself is excised. A biopsy of the cyst wall is recommended for tissue confirmation. Complete removal of the sublingual gland is difficult with this approach, requiring division of the mylohyoid muscle and dissection up to the floor of the mouth.
Some surgeons recommend a transoral excision of the gland with drainage of the cyst first.
If that fails, complete excision of the cyst via a transcervical approach is indicated. A transcervical approach also is indicated for ranulas located exclusively in the neck. Plunging ranulas Risk for paresis and paralysis of the marginal mandibular nerve is increased, as the nerve often lies just on the surface of the cyst. Drainage of the cyst following identification of the nerve often can reduce risk for postoperative complications. Because the risk to adjacent structures is higher for gland-excising procedures, a trial of less invasive procedures is advocated by some.