Ranula (Upajihwika) Oral Disorder – Symptoms, Ayurvedic Treatment

By Dr Raghuram Y.S. MD (Ay) & Dr Manasa, B.A.M.S
Upajihwika is a diseased condition of the tongue in which there is a swelling resembling the ‘tip of the tongue’ beneath the tongue. It looks like a small / sub tongue beneath the tongue and hence the name.

Introduction, category, pathogenesis

Upa = sub
Jihwa / jihvika = tongue
Read – Ayurvedic Tongue Examinations Explained In Vaidya Sara Sangraha

Category –
Upajihvika is a disorder which has been described under mukhagata rogas (diseases of the oral cavity).
This condition occurs in relation to the tongue. Therefore, ‘Upajihvika oral disorder’ has been sub-classified and categorised under Jihwagata Rogas (diseases of the tongue)
Jihwagata rogas is a category which falls under the umbrella of mukhagata rogas (diseases of the oral cavity).
Read – Ayurvedic Remedies, Treatment, Medicines For Halitosis (Bad Breath)

Pathogenesis of upajihwika tongue disorder
When the vitiated kapha and blood afflict the tongue, upajihwika / upajihwa tongue disorder is formed beneath the tongue in the form of a swelling.
Read – Dry Mouth Causes, Ayurvedic Treatment, Remedies, Tips, Diet

Symptoms, sanskrit verse, treatment

Symptoms of Upajihwa tongue disorder

  • Jihwa agra rupa shwayathu jihwam unnamya jaatah – a swelling resembling the tip of the tongue is formed beneath the tongue
  • Praseka – watering of the mouth, nausea
  • Kandu – itching of the tongue
  • Paridaha – burning sensation in the tongue and mouth
    Read – Mouth Ulcers Ayurvedic Treatment, Medicines, Remedies, Tips

Treatment of Upajihwa tongue disorder
According to master Sushruta, the below mentioned measures should be followed in the treatment of Upajihwa tongue disorder –

  • Lekhana karma – scraping the swelling
  • Kshaara karma – after scraping the swelling, alkalis shall be applied to the wound (read more)
  • Shirovirechana – purgatory nasal medication
  • Gandusha vidhi – full mouth gargles with medicated fluids
  • Dhuma vidhi – medicated smoking
    Read – Dhumapana Vidhi Adhyaya Ashtanga Hridaya Sutrasthana 21

Yogaratnakara text mentions the below mentioned remedies –

Vyoshadi Churna Gharshana – the swelling beneath the tongue should be rubbed with powder of the below mentioned herbs –

Vyoshadi taila abhyanga – the oil processed and prepared with the above mentioned vyosha etc herbs should be used for administering massage over the mass beneath the tongue.
Read – Trikatu Churna Benefits, Dose, Remedies, Side Effects

Gruhadhumadi churna / kalka lepa – application of the powder / paste prepared from the below mentioned herbs should be made (over the swelling of upajihwa) –

  • Gruhadhuma – soot of chimney in the houses
  • Kanji i.e. medicated fermented liquid
  • Honey (read more)
  • Rock salt

Mardana – swelling should be gently rubbed with fingers.

Nirgundi patra – Musali kanda charvana – person suffering from upajihwa should be allowed to chew leaves of Vitex negundo and tuber of Asparagus adscendens.
Read – Nirgundi – Vitex negundo Uses, Dose, Side Effects, Research

Modern medicine prefers complete removal of ranula through surgical measures. The remaining part of ranula, which couldn’t be removed and is left out, will be subjected to diatherapy / cauterization.
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Modern correlation
Upajihwa tongue disorder can be closely correlated with a condition called ‘Ranula’ explained in modern medicine. (read more)

Ranula

Ranula – Causes, Symptoms, Prevention, Treatment

A ranula is a cystic swelling found on the floor of the mouth, below the tongue to be precise. It is a type of mucocele and involves a sublingual gland.

Word Derivative –
Word is derived from a Latin term ‘Rana’ which means frog. Therefore Ranula means ‘a little frog’. The swelling of ranula looks like a little frog in the floor of the mouth.

Causes, pathology, symptoms

How is Ranula caused?
Ranula presents as a swelling of connective tissue. When a local trauma to the mouth floor causes rupture of salivary gland, mucin is discharged. The swelling of the ranula consists of this mucin.

If the ranula is small and doesn’t present with nay symptoms, treatment will not be needed. Other cases of ranula require a minor surgery to be done.

Causes of Ranula
There are some salivary glands beneath the tongue which produce saliva. They are called sublingual glands. They drain the saliva that they had produced into the oral cavity through salivary ducts.

When there is minor trauma to the floor of the mouth, it damages these ducts. The consequent lesion is a mucocele of the oral floor (mucus extravasation cyst). Ranula is larger in size in comparison to the other mucoceles. They grow to such larger sizes so as to occupy the entire mouth.

Mucoceles can also take their origin from the submandibular duct or the minor salivary glands in the mouth floor. Ranula may rarely extend backwards to the parapharyngeal space. The fluid contained in the ranula is viscous. It has jelly like consistency of egg white.

Patho-physiology of Ranulae
Obstruction – Partial obstruction of sublingual duct may cause formation of ranulas. In this case, a retention cyst lined by epithelial tissue is formed. This is uncommon condition. It occurs in less than 10% of all ranulas.

Trauma – Trauma also causes ranulas. Trauma leads to the formation of extravasated saliva. This causes ranulas.

Plunging Ranulas:
These ranulas arise in the neck. One of the below mentioned mechanisms are followed –

The sublingual gland may project through the mylohyoid muscle. Alternatively, an ectopic sublingual gland may already exist on the cervical side of mylohyoid. In these conditions, there is no oral component of ranula.

A pseudocyst may penetrate through the mylohyoid through the sites of dehiscence in the muscle. Sometimes, surgical trauma by operations done on ranula previously may scar the surface of ranula. When the ranula recurs, the path of least resistance is through a dehiscent mylohyoid muscle and a plunging ranula forms when only a simple ranula was initially present.

A duct from sublingual gland may join the submandibular gland / duct. This causes ranulas to form in continuity with sub-mandibular gland. The ranula reaches the neck from behind the mylohyoid muscle.

Signs and Symptoms of Ranula
Swelling occurs in the connective tissue of the floor of the mouth and has below mentioned features –

  • Blue color
  • Dome-shaped
  • Translucent
  • Fluctuant
  • Movable
  • No blanching
  • Painless (becomes painful when it gets infected)

If the lesion is deeper with thick tissues, blue transparent appearance may not be seen.
Location of Ranula – Usually located lateral to midline of tongue. This differentiates it from the midline dermoid cyst.
Elevation of the tongue and difficulty in swallowing food – This happens when the ranula is a large lesion with large diameter.
Inconsistent nature – Ranulae can fluctuate rapidly in size, may shrink and swell often and intermittently.
Rupture of ranula – Ranulae may rupture and may cause recurrent swelling in due course of time.
Cervical Ranula – presents as a swelling in the neck with or without an oral swelling.

Renula complications, diagnosis, classification

Complications of Ranula
Ranula may get associated with one or more of the below mentioned complications.

  • It may burst open and reform once again
  • Difficulty in swallowing food and fluids when the size of the ranula is large
  • Difficulty in speaking
  • The ranula may get subjected to repeated trauma
  • It may also get infected
  • Ranula may recur after draining a cyst

Complications following surgical intervention –

  • Temporary tongue numbness
  • Post-surgery hematoma
  • Infection – suggested by presence of fever, pain and chills

Diagnosis of Ranula
Presence of foamy histiocytes – There is mucin spill from the ranula. This spilled mucin forms a granulation tissue. This tissue contains foamy histiocytes which is typical of ranula. The histologic appearance is similar to other mucoceles, elsewhere in the body.

Ultrasound and MRI – These may be useful to image the ranula lesion.

Criteria for diagnosis – the below mentioned criteria will help in clinching the diagnosis of ranula. Therefore they should be considered and observed in case of lump in the oral floor –

  • If it is a ranula, there is a painful swelling in the floor of the mouth. Sometimes pain may be absent.
  • Tenderness is not present.
  • Presence of ranula is mostly unilateral. It is present on one side of the midline of the undersurface of the tongue i.e. tongue frenulum.
  • Ranula is spherical in shape.
  • Its size varies from 1-5 cm in diameter.
  • Ranula carries a pale blue color.
  • It is semi-transparent in appearance.
  • It shows positive fluctuation and transillumination tests.
  • There is no enlargement of cervical lymph nodes.
  • They may or may not have prolongation in the neck.
  • Ranula is seen in young children and adoslescents
  • It affects both genders equally.

Differential diagnosis of Ranula
Pleomorphic adenoma – common benign salivary gland neoplasm, it is the most common type of salivary gland tumour.
Thyroglossal duct cyst – is an embryologic remnant that forms due to failure of closure of thyroglossal duct. It extends from foramen cecum in the tongue to the thyroid’s location in the neck.
Cervical thymic cyst – unusual lesions presenting in 1st decade of life and represents 1% of cervical masses.
Cystic hygroma – fluid filled sac that results from blocks in lymphatic system. It is commonly located in the neck or head, can occur anywhere. Dermoid cyst – sac like growth present at birth. They usually occur on the face, inside the skull or lower back.
Infantile hemangioma – a type of benign vascular tumor which occurs in babies in the form of red or blue raised lesions.
Laryngocele – is a congenital anomalous air sac communicating with cavity of larynx. It may bulge outward on the neck.
Lipoma – is a slow growing, fatty lump, most often situated between skin and underlying muscle layer.
Abscess – painful collection of pus usually caused by infection.
(Read more)

Classification of Ranula
Ranula can be classified as and under ‘disorder of the salivary glands’. This is because ranula is a type of mucocele.

Classification based on the location of ranulae
Simple Ranula – when the ranula is confined to the floor of the mouth.

Plunging / deep / diving Ranula / Cervical Ranula / Oral ranula with cervical extension – it is a variant of ranula which presents with a swelling similar to ranula in the neck instead of the floor of the mouth. They occur in conjunction with oral ranulas. They may also occur independently. This is characterised by mucus extravasation, its extension below the mylohyoid muscle and extra-oral neck swelling which is visible.

Other classification
Congenital ranulas – They may arise secondary to an imperforate salivary duct or ostial adhesion. They are rare in occurrence and are known to spontaneously resolve.
Post-traumatic ranulas (Mucus Extravasation Reaction – MER) – occur due to trauma to sublingual gland / ducts, leading to extravasation of mucus and formation of a pseudocyst.
(Read more)

Prognosis of Ranula
Even after surgical excision, recurrence of the ranula is a possibility.
Some ranulas resolve by themselves, spontaneously.

Ranula prevention, home remedies

Prevention of Ranula
It is said that there are no known / proven measures to prevent ranulae as of now.
Still, the below mentioned measures shall be considered as preventive of ranulae –

  • Avoid local trauma to the salivary glands
  • Avoid habits that irritate salivary glands, example – sucking or chewing on lips or tongue
  • Avoid rubbing of oral mucosa against sharp / fractured teeth or orthodontics appliances
  • Prompt treatment of the mucosal diseases which cause these mucoceles
  • Moist oral environment should be maintained through hydration or use of oral lubricants / moisturizers (if xerostomia is a contributory factor)

The following measures which could prevent oral irritation that could lead to rupture of ranula and spillage of mucin into surrounding mucosa shall be encouraged to be followed –

  • Discontinuing the contributory habits
  • Restoring damaged teeth
  • Use of orthodontic wax with oral appliances
  • Wearing mouth guards in sports

Home Remedies for Ranula

Oil of Primrose and Oregano oil – Oil of primrose containing omega-6 fatty acids is found to be a useful remedy in ranula according to a study. It helps reduce inflammation when applied on the swelling. Similarly Oregano oil shall be applied on the swelling.
Apple cider vinegar – 1 teaspoon of apple cider vinegar mixed in a cup of warm water is given for mouth rinsing. Later the mouth shall be rinsed with normal warm water.
Honey and Tea tree oil – A mixture of half teaspoon honey and 2-3 drops of tea tree oil should be applied on the swelling. Mouth should be rinsed after couple of minutes.
Lemon juice – lemon juice shall be applied on ranula using a cotton swab dipped in it.
Turmeric – Paste of turmeric made in water or milk is applied on the ranula.
Sage leaves – 3 teaspoons of dried sage leaves is left to steep in hot water. Later it is strained and used for gargle.
Alum – After keeping the alum in contact with ranula for few minutes, the patient should be asked to rinse his mouth with water.
Myrrh – 1-2 drops of myrrh tincture should be dropped on the cotton swab and applied on the ranula.
Aloe Vera – apply aloe vera juice on the ranula. Rinse your mouth with lukewarm water after 15-20 minutes.
Tea Bags – After steeping the tea bag in hot water, it is placed in refrigerator for 15-20 minutes to cool it down. This cold and moist tea bag is placed in contact with ranula for 10-12 minutes.
Ice – apply ice cubes tied in a sterile cloth to the ranula.
Sea Salt – The person should be advised to rinse his mouth with lukewarm water mixed with half teaspoon of sea salt / table salt.
Baking soda – Paste of baking soda made with water should be applied on ranula. The mouth shall be rinsed after 8-10 minutes.
Hydrogen Peroxide – A piece of cotton swab dipped in 3% hydrogen peroxide is applied on the ranula.
Glycerin – Dab some glycerin on the ranula and later rinse the mouth with lukewarm water. Likewise, glycerin based mouth washes should be used. Yogurt – eating yoghurt with meals will help in ranula.

Treatment, epidemiology

Treatment of Ranula
Surgical intervention – If the ranula is small or asymptomatic, it doesn’t need any surgical intervention. Else, treatment of ranula usually involves surgical removal of the sublingual gland. Surgery is needed for enlarged ranulas, especially when they meddle with swallowing and speaking. (3)

Marsupialization – It is the method of opening the intra-oral lesion into the oral cavity. This is done so sublingual gland re-establish connection with oral cavity.

Injections – If there is pain, the doctor may recommend an injection of steroid into the skin beneath the cyst, into the lesion.
(Read more)

Epidemiological facts
Ranula is usually present in the children. Ranulae are the most common pathological lesion associated with sublingual glands. Lesions occur most often in the first three decades.

Most reported ranulae usually exist in close association with oral mucoceles. Reported male : female ratio – 1:1.3

Interesting points about Ranulae
Hippocrates has considered ranulae to be secondary to inflammation.
Pare opines that the ranulas may represent descent of brain or pituitary matter. (reference)

Click to Consult Dr Raghuram Y.S. MD (Ayu) – Email / Skype

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