Uvulitis

Uvulitis
Uvular Edema portion of image courtesy of Dr. Christyn Magill @ CMC.

We cannot afford to be cavalier in our jobs. What is, on the surface, seemingly simple, may be more complex. Take for example, the “Sore Throat.” Sure, it is likely “just a virus” (which we should never say out loud), but we are diligent and consider a number of other etiologies (ex, Strep Pharyngitis, Retropharyngeal Abscess, Peritonsillar Abscess, Tracheitis, and Epiglottitis). Recently, one of my esteemed colleagues, Dr. Christyn Magill, asked whether a markedly swollen uvula would make me consider something more ominous… and I cavalierly said, “I’m sure it’s just a virus.” Fortunately, my less than thoughtful response seems to have been correct… but let is take a minute to see how wrong I could have been. Let’s review the potential associations of Uvulitis:

Uvulitis: Basics

  • Uvulitis = swelling and inflammation of the uvula (simple enough)
  • Has a reported “low incidence.” [McNamara, 1994; Aquino, 1992; Kotloff, 1983]
    • Not often addressed in medical textbooks. [Kotloff, 1983]
    • Literature consists primarily of case reports and cases series. [McNamara, 1994; Kotloff, 1983]
  • Anatomy:
    • Uvula is composed of mostly of connective tissue and mucous and salivary glands.
    • It also contains fibers of the musculus uvulae muscle.
      • Allows it to change shape and contour.
      • Allows it to assist with swallowing and phonation.
    • At rest, its position is adjacent to supraglottic structures (ex, the epiglottis).
    • It is innervated by the vagal nerve’s pharyngeal branch.
  • Presentations: [McNamara, 1994]
    • Fever
    • Sore Throat
    • Odynaphagia
    • Dysphagia
    • Dyspnea

Uvulitis: Associations & Causes

  • Uvulitis can be due to anything that causes local inflammation or irritation. [Shiber, 2014; Aquino, 1992]
    • Infection
      • Viral Infection
      • Group A Strep
      • Hemophilus influenzae [Aquino, 1992]
        • Associated with epiglottis, pharyngitis, and septic arthritis.
        • Obviously less common with widespread use of Hib vaccination (since the 1990’s).
      • Anaerobic bacterium [Brook, 1997]
      • Fungal
    • Allergic Reaction
    • Direct Injury [Gilmore, 2012]
    • Caustic or Thermal Injury
    • Immunologic / Rheumatologic / Vasculitis – some cases associated with Kawasaki Disease. [Kazi, 1992]
    • Non-infectious edema is sometimes referred to as Quincke’s Disease.
  • Severe Uvulitis described as having two clinical syndromes: [Wynder, 1986; Kotloff, 1983]
    • Associated with Group A Strep
      • Often with impressive redness and swelling
      • Not associated with airway obstruction
    • Associated with Hemophilus influenzae and Epiglottitis!
  • Patients with Uvulitis due to bacterial infection have also been found to have concurrent bacteremia. [Aquino, 1992; Wynder, 1986]
    • Yet another reason to support vaccinations!

Uvulitis: Management

  • Most often management is symptomatic.
  • A good vaccination history is warranted… did they get Hib Vaccine??
  • Look like they have epiglottis? Treat them that way.
    • Keep everyone calm.
    • Go to the OR.
  • Not toxic, but has concerning exam? Then;
    • Consider lateral soft tissue neck film:
      • Looking for possible subtle epiglottis.
      • Especially if not vaccinated.
    • Get surface and blood cultures. [Aquino, 1992; Wynder, 1986]
    • May consider nebulized epinephrine.
  • Not toxic and not concerning exam?
    • Well… then be reasonable. It is likely a benign and/or self-limited etiology. [McNamara, 1994]
    • Consider non-infectious etiologies.
    • It is likely that the epidemiology of uvulitis has changed substantially since the more widespread use of Hib vaccination… so concerns described in literature from the 1980’s and early 1990’s may be less applicable today.
    • Treat symptoms, but give good anticipatory guidance.

Moral of the Morsel

  • Vaccinations save lives! Simple as that.
  • Swelling may not be limited to the uvula. Consider the adjacent structures (ie. the epiglottis).
  • May just be the tip of the iceberg... but it may also be just an annoyance.

References

Shomali W1, Holman K2. Concurrent uvulitis and epiglottitis. Cleve Clin J Med. 2016 Oct;83(10):712-714. PMID: 27726831. [PubMed] [Read by QxMD]
Shiber JR1, Fontane E1. Quincke’s Disease: isolated uvulitis. West J Emerg Med. 2014 Sep;15(6):663. PMID: 25247038. [PubMed] [Read by QxMD]
Ziahosseini K1, Ali S2, Simo R3, Malhotra R1. Uvulitis following general anaesthesia. BMJ Case Rep. 2014 Sep 23;2014. PMID: 25249220. [PubMed] [Read by QxMD]
Gilmore T1, Mirin M. Traumatic uvulitis from a suction catheter. J Emerg Med. 2012 Dec;43(6):e479-80. PMID: 22056547. [PubMed] [Read by QxMD]
Boyce SH1, Quigley MA. Uvulitis and partial upper airway obstruction following cannabis inhalation. Emerg Med (Fremantle). 2002 Mar;14(1):106-8. PMID: 11993827. [PubMed] [Read by QxMD]
Peghini PL1, Salcedo JA, Al-Kawas FH. Traumatic uvulitis: a rare complication of upper GI endoscopy. Gastrointest Endosc. 2001 Jun;53(7):818-20. PMID: 11375603. [PubMed] [Read by QxMD]
Brook I1. Uvulitis caused by anaerobic bacteria. Pediatr Emerg Care. 1997 Jun;13(3):221. PMID: 9220512. [PubMed] [Read by QxMD]
Roberge RJ, Sullivan T. Topical epinephrine therapy of acute uvulitis. Am J Emerg Med. 1997 May;15(3):331-2. PMID: 9149007. [PubMed] [Read by QxMD]
McNamara RM1. Clinical characteristics of acute uvulitis. Am J Emerg Med. 1994 Jan;12(1):51-2. PMID: 8285973. [PubMed] [Read by QxMD]
Kazi A1, Gauthier M, Lebel MH, Farrell CA, Lacroix J. Uvulitis and supraglottitis: early manifestations of Kawasaki disease. J Pediatr. 1992 Apr;120(4 Pt 1):564-7. PMID: 1552395. [PubMed] [Read by QxMD]
Aquino V1, Terndrup TE. Uvulitis in three children: etiology and respiratory distress. Pediatr Emerg Care. 1992 Aug;8(4):206-8. PMID: 1513729. [PubMed] [Read by QxMD]
Hawke M, Kwok P. Acute inflammatory edema of the uvula (uvulitis) as a cause of respiratory distress: a case report. J Otolaryngol. 1987 Jun;16(3):188-90. PMID: 3599176. [PubMed] [Read by QxMD]
Wynder SG, Lampe RM, Shoemaker ME. Uvulitis and Hemophilus influenzae b bacteremia. Pediatr Emerg Care. 1986 Mar;2(1):23-5. PMID: 3490655. [PubMed] [Read by QxMD]
Li KI, Kiernan S, Wald ER, Reilly JS. Isolated uvulitis due to Haemophilus influenzae type b. Pediatrics. 1984 Dec;74(6):1054-7. PMID: 6334271. [PubMed] [Read by QxMD]
Kotloff KL, Wald ER. Uvulitis in children. Pediatr Infect Dis. 1983 Sep-Oct;2(5):392-3. PMID: 6356061. [PubMed] [Read by QxMD]

Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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3 Responses

  1. Stephen Gamboa says:

    less common in kids, but don’t forget angioedema

  2. Hi Sean, When is the right time to visit Doctor and what kind of Doctor to Visit? More often, it’s happening during winter. It’s related tot he weather mostly. Is there any homemade remedy for Sore Throat, if it’s just started?

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