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