Doctor123.org

Uvulitis, Emergency Medicine

Basics

Description

- 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

- HEENT: - Erythematous or pale uvula - Uvular edema - Exudate (present on uvula or oral pharynx) - Cervical lymphadenopathy - Pharyngitis

- Associated findings: - Fever - Hypoxia - Urticaria - Wheezing

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

- Definitive airway: - Endotracheal intubation: - Rapid sequence - Delayed sequence/awake - Fiberoptic assist and indirect laryngoscopy

- 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

- Purified C1 inhibitor concentrate: - Berinert: 20 U/kg IV 1 - Cinryze: 1,000 U IV

- 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

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

  • Infectious:
  • 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 commonHaemophilus influenzae type b (Hib)Other bacterial infections (Fusobacterium nucleatum, Provetella intermedia, Streptococcus pneumonia)Viral:Not well reported but suspected in mild/transient casesKnown to cause uvular lesions however rare in isolationCoxsackie virus (other enteroviruses)Herpes simplex virusVaricella-zoster virusEpstein " Barr virusCandidal infections
  • Noninfectious:Trauma/procedure relatedInhalation/ingestion of chemical or thermal irritantsVasculitisAllergicAngioedema:HereditaryMedication 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 sensationSore throatDysphagiaOdynophagiaDyspnea
  • Infectious:
  • Noninfectious:Trauma or recent procedureNew 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 " appearanceMuffled or "hot-potato " voiceDroolingStridorGaggingRespiratory distress
  • HEENT:Erythematous or pale uvulaUvular edemaExudate (present on uvula or oral pharynx)Cervical lymphadenopathyPharyngitis
  • Associated findings:FeverHypoxiaUrticariaWheezing

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 infectionEosinophilia suggesting allergic etiology
  • Complement testing:Elevated C4 level suggesting esterase deficiencyC1 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 endoscopyCricothyrotomyUvular aspiration/decompressionUvulectomy

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 oxygenNebulized ²-agonists or racemic epinephrine
  • Definitive airway:Endotracheal intubation:Rapid sequenceDelayed sequence/awakeFiberoptic assist and indirect laryngoscopyCricothyrotomy 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 dosesDiphenhydramine: 25 " 50 mg (peds: 1 " 2 mg/kg) IVMethylprednisolone: 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 q8hEmpiric oral antibiotic options:Penicillin V: 500 mg (peds: <27 kg 250 mg, >27 kg 500 mg) PO BID " TID 10 daysAmoxicillin: 875 mg (peds: 50 mg/kg/d PO div. q8h) PO q8h 10 daysClindamycin: 300 mg (peds: 25 " 40 mg/kg) PO QID 10 days
  • Suspected hereditary angioedema:Anabolic steroid:Danazol: 200 mg PO BID " TIDPurified C1 inhibitor concentrate:Berinert: 20 U/kg IV 1Cinryze: 1,000 U IVSelective bradykinin B2-receptor antagonist:Icatibant: 30 mg SC 1Reversible 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 requirementOngoing respiratory compromiseInability to tolerate oral intakeIntractable 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)