Uvulitis, Emergency Medicine

Basics

Description

Uvulitis refers to any inflammatory condition involving the uvula. Uvulitis can be separated into 2 broad categories:

Infectious:
- Bacterial
- Viral
- Candidal
Traumatic or noninfectious

Epidemiology

Incidence and Prevalence Estimates

Exact incidence is unknown owing to limited reporting
Once thought to be rare but may in fact be more common (e.g., viral etiologies)
Children (age 5 " 15) more often affected than adults due to prevalence of group A streptococcal infections in this age group
Noninfectious causes more common than infectious causes in adult population

Etiology

Infectious:
- Bacterial:
  - Group A streptococcal infection (GAS), most common
  - Haemophilus influenzae type b (Hib)
  - Other bacterial infections (Fusobacterium nucleatum, Provetella intermedia, Streptococcus pneumonia)
- Viral:
  - Not well reported but suspected in mild/transient cases
  - Known to cause uvular lesions however rare in isolation
  - Coxsackie virus (other enteroviruses)
  - Herpes simplex virus
  - Varicella-zoster virus
  - Epstein " Barr virus
- Candidal infections
Noninfectious:
- Trauma/procedure related
- Inhalation/ingestion of chemical or thermal irritants
- Vasculitis
- Allergic
- Angioedema:
  - Hereditary
  - Medication induced (e.g., Angiotensin-converting enzyme inhibitor [ACEi], Angiotensin receptor blocker [ARB])

Diagnosis

Signs and Symptoms

Dependent upon etiology and associated structural involvement (pharyngitis, epiglottitis, laryngitis, etc.)
History

Generally rapid in onset (<4 " 6 hr) depending on etiology
All types:
- Foreign-body sensation
- Sore throat
- Dysphagia
- Odynophagia
- Dyspnea
Infectious:
- Fever (reported)
Noninfectious:
- Trauma or recent procedure
- New medication exposure (ACEi)
- Caustic or thermal ingestion
Prior event of tongue, lip, or mouth swelling
Immunization history in pediatric population
Medical comorbidity leading to immune compromise

Physical Exam

Ranging from limited and well appearing to severe and marked distress
General:
- "Toxic " appearance
- Muffled or "hot-potato " voice
- Drooling
- Stridor
- Gagging
- Respiratory distress
HEENT:
- Erythematous or pale uvula
- Uvular edema
- Exudate (present on uvula or oral pharynx)
- Cervical lymphadenopathy
- Pharyngitis
Associated findings:
- Fever
- Hypoxia
- Urticaria
- Wheezing

Essential Workup

Evaluation and stabilization of airway as needed
Determine infectious vs. noninfectious etiology
Initiate treatment based on suspected etiology (antibiotics, steroids, antihistamine, etc.)
Consultation with otolaryngologist as warranted

Diagnosis Tests & Interpretation

Lab

Rapid GAS antigen
Surface mucosa bacterial culture
CBC:
- Leukocytosis suggesting bacterial infection
- Eosinophilia suggesting allergic etiology
Complement testing:
- Elevated C4 level suggesting esterase deficiency
- C1 esterase immunochemical assay

Imaging

Used to rule out other conditions in the differential diagnosis when clinical suspicion exists or when physical exam is limited
Lateral neck x-ray to visualize and evaluate the epiglottis or for foreign-body aspiration
CT scan soft tissue neck with IV contrast to evaluate for space occupying fluid collection, cellulitis, deep tissue involvement

Diagnostic Procedures/Surgery

As warranted and in consultation with otolaryngology when severity of disease warrants:
- Fiberoptic nasopharyngeal endoscopy
- Cricothyrotomy
- Uvular aspiration/decompression
- Uvulectomy

Differential Diagnosis

Pharyngitis
Peritonsillar abscess
Retropharyngeal abscess
Epiglottitis
Angioedema
Aspirated foreign body

Treatment

Pre-Hospital

Rapid assessment of airway, definitive management as warranted
Supplemental oxygen
Peripheral IV access
Assessment of patient surroundings, potential ingestions/inhalants
Per pre-hospital protocol, IM epinephrine injection, nebulized ²-agonist, or racemic epinephrine
Rapid/emergent transport

Initial Stabilization/Therapy

Initial focus on managing ABCs
Rapid assessment of airway and need for definitive management
Peripheral IV access
Cardiac and oxygen saturation monitoring
Continued pre-hospital therapy or initiate respiratory therapy:
- Supplemental oxygen
- Nebulized ²-agonists or racemic epinephrine
Definitive airway:
- Endotracheal intubation:
  - Rapid sequence
  - Delayed sequence/awake
  - Fiberoptic assist and indirect laryngoscopy
- Cricothyrotomy in severe cases
Early consultation with otolaryngology as warranted

Ed Treatment/Procedures

Basic ED treatment is focused on rapid reversal of inflammatory conditions (allergic, angioedema)
Oral therapy vs. parenteral dependent upon severity of condition

Medication

Severe conditions (airway compromise):
- Epinephrine, 1:1,000: 0.3 " 0.5 mg (peds: 0.01 mg/kg) SQ or IM q30min 3 doses
- Diphenhydramine: 25 " 50 mg (peds: 1 " 2 mg/kg) IV
- Methylprednisolone: 125 mg (peds: 0.5 " 1 mg/kg) IV q4h
Suspected infectious etiology:
- Empiric parenteral antibiotic to cover most common etiologies (GAS and Hib)
- Several options based on patient profile/allergy:
  - Ceftriaxone: 1 " 2 g (peds: 50 mg/kg) IV (max. dose 2 g/d)
  - Clindamycin: 300 mg (peds: 25 " 40 mg/kg) IV q8h
- Empiric oral antibiotic options:
  - Penicillin V: 500 mg (peds: <27 kg 250 mg, >27 kg 500 mg) PO BID " TID 10 days
  - Amoxicillin: 875 mg (peds: 50 mg/kg/d PO div. q8h) PO q8h 10 days
  - Clindamycin: 300 mg (peds: 25 " 40 mg/kg) PO QID 10 days
Suspected hereditary angioedema:
- Anabolic steroid:
  - Danazol: 200 mg PO BID " TID
- Purified C1 inhibitor concentrate:
  - Berinert: 20 U/kg IV 1
  - Cinryze: 1,000 U IV
- Selective bradykinin B2-receptor antagonist:
  - Icatibant: 30 mg SC 1
- Reversible inhibitor of plasma kallikrein:
  - Ecallantide: 30 mg SQ 1 (as 3 " 10 mg injections)
- Fresh frozen plasma:
  - Generally not for acute attacks

Follow-Up

Disposition

Disposition dependent upon severity of condition and response to therapy
Admission Criteria

Severe airway obstruction warranting definitive airway and ventilatory management
Need for surgical intervention
Indication of systemic bacterial infection and need for parenteral antibiotics
Moderate to severe conditions not responsive to treatment:
- Hypoxia or oxygen requirement
- Ongoing respiratory compromise
- Inability to tolerate oral intake
- Intractable pain
Significant comorbid illness
Poor social conditions limiting outpatient care

Discharge Criteria

Rapid reversal of condition
Observation in the ED for 4 " 6 hr without recurrent symptoms
No respiratory compromise
Able to tolerate oral medications and liquids
Close follow-up available within 24 " 48 hr
Access to prescription medications

Issues for Referral
History of recurrent angioedema warrants adjustment of medication, possible referral to Otolaryngology

Follow-Up Recommendations

Severe infectious etiologies warrant close follow-up with primary physician (24 " 48 hr) to ensure improvement
For suspected angioedema, immediately discontinue use of ACEi and ARB

Pearls and Pitfalls

Uvulitis can be caused by several etiologies ranging from infection to hereditary disorder
Treatment should be directed toward the suspected etiology based on history and exam
Uvulitis in isolation rarely causes respiratory compromise. If severe respiratory distress, look for additional causes (epiglottitis, anaphylaxis, retropharyngeal abscess, etc.)
Emergent definitive airway management should be anticipated with tools, medications, and other resources kept near the patient at all times
Early consultation with otolaryngology when anticipated

Additional Reading

Buyantseva LV, Sardana N, Craig TJ. Update on treatment of hereditary angioedema. Asian Pac J Allergy Immunol. 2012;30:89 " 98.
Cohen M, Chhetri DK, Head C. Isolated uvulitis. Ear, Nose & Throat J. 2007;86:462, 464.
Gilmore T, Mirin M. Traumatic uvulitis from a suction catheter. J Emerg Med. 2012;43:479 " 480.
Lathadevi HT, Karadi RN, Thobbi RV, et al. Isolated uvulitis: An uncommon but not a rare clinical entity. Indian J Otolaryngol Head Neck Surg. 2005;57:139 " 140.
Mohseni M, Lopez MD. Images in emergency medicine: Uvular Angioedema. Ann Emerg Med. 2008;51:8, 12.

Codes

ICD9

528.3 Cellulitis and abscess of oral soft tissues

ICD10

K12.2 Cellulitis and abscess of mouth

SNOMED

300932000 Uvulitis (disorder)

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