Acute Uvulitis

Acute uvulitis is inflammation and swelling of the uvula, which becomes red, oedematous and sometimes translucent. It is uncommon but can be dangerous because swelling can threaten the airway, so the first task is always an airway assessment. It occurs in children and adults and has infective, allergic, traumatic, irritant and hereditary causes.

• Infective: group A streptococcus, Haemophilus influenzae (including type b in unvaccinated children), Streptococcus pneumoniae, Staphylococcus aureus, viruses (influenza, adenovirus, EBV), Candida in immunosuppressed patients.
• Allergic and angioedema: food, drugs (penicillins, NSAIDs, aspirin), insect stings, ACE inhibitor angioedema, hereditary angioedema (C1 esterase inhibitor deficiency), idiopathic.
• Trauma and irritation: intubation, nasogastric tubes, endoscopy, vigorous snoring, vomiting, coughing, hot food or drink, chemicals, smoking, heavy alcohol use, radiotherapy, dehydration, uvular elongation.
• Others: Stevens-Johnson syndrome, Kawasaki disease, hereditary conditions, uvular necrosis after sleeve gastrectomy or direct trauma.
• Complications: airway obstruction (stridor, respiratory distress), dysphagia, aspiration, abscess, extension to deep neck spaces.

• Sore throat, foreign body or gagging sensation, difficulty swallowing, voice change (muffled "hot potato" voice), drooling, cough, nausea and vomiting, difficulty breathing when lying flat, fever if infective.
• Examination: red, swollen, elongated uvula (may be pale and translucent in allergic oedema), sometimes touching the tongue base; check for urticaria, lip or tongue swelling, tonsillar enlargement, pus, trismus.
• Red flags (immediate airway risk): stridor, drooling, tripod posture, inability to swallow saliva, voice change, cyanosis, severe dyspnoea, rapid progression, tongue or lip swelling, hypotension, wheeze (anaphylaxis), history of ACE inhibitor use, family history of angioedema, epiglottitis features, neck swelling or trismus (deep neck infection), fever with toxic appearance, immunosuppression.

• Clinical diagnosis. Assess airway, breathing and circulation first, with saturations.
• Oropharyngeal examination with a light and tongue depressor (avoid in suspected epiglottitis). Flexible nasolaryngoscopy for airway assessment in an adult with significant swelling.
• Throat swab for rapid streptococcal antigen or culture; full blood count, CRP, blood culture if febrile or toxic.
• Allergy history: new foods, medicines, stings. C4, C1 esterase inhibitor level and function if recurrent angioedema without urticaria or with family history. Tryptase if anaphylaxis suspected.
• Lateral neck X-ray or CT neck with contrast if deep neck infection or epiglottitis is suspected.
• Differentials: epiglottitis, peritonsillar abscess, retropharyngeal abscess, tonsillitis, angioedema, anaphylaxis, foreign body, uvular trauma, Ludwig angina, herpangina.

• Airway first: sit upright, give oxygen, urgent senior and anaesthetic or ENT help if any airway concern; never lie the patient flat; avoid sedation; admit for observation.
• Allergic or angioedema cause:
  • Adrenaline (epinephrine) 0.5 mg (0.5 mL of 1 mg/mL) intramuscularly into the anterolateral thigh for anaphylaxis or airway threat in adults (children: 0.01 mg/kg; 150 micrograms under 6 years, 300 micrograms 6 to 12 years), repeated after 5 minutes if needed. Nebulised adrenaline 1 mg/mL, 5 mL, can be used for upper airway oedema.
  • Chlorphenamine 10 mg intravenously or intramuscularly (adult) or cetirizine 10 mg orally.
  • Hydrocortisone 200 mg intravenously (adult) or dexamethasone 8 to 10 mg orally or intravenously as a single dose (children 0.15 to 0.6 mg/kg, maximum 10 mg).
  • Stop and avoid the culprit drug. ACE inhibitor angioedema does not respond to antihistamines or steroids; manage the airway and stop the drug permanently; icatibant 30 mg subcutaneously may be used.
  • Hereditary angioedema: C1 esterase inhibitor concentrate 20 units/kg intravenously (or icatibant 30 mg subcutaneously), specialist care.
• Infective cause:
  • Phenoxymethylpenicillin 500 mg orally four times daily for 10 days (children by weight/age), or amoxicillin 500 mg three times daily; for severe infection or a suspected invasive pathogen: ceftriaxone 1 to 2 g intravenously once daily (children 50 to 80 mg/kg daily) with admission.
  • Penicillin allergy: clarithromycin 500 mg orally twice daily for 7 days, or clindamycin 300 to 450 mg four times daily.
  • Dexamethasone 8 to 10 mg single dose (children 0.15 to 0.6 mg/kg) to reduce swelling.
• Supportive: cool fluids, ice chips, paracetamol 1 g orally every 6 hours (maximum 4 g per day), ibuprofen 400 mg every 8 hours with food (avoid if allergic angioedema is NSAID related), gargles with cool saltwater, humidified air, voice rest; avoid hot or irritant foods, alcohol and smoking.
• Trauma and irritation: remove the cause, cooling, dexamethasone 0.15 to 0.6 mg/kg orally as a single dose (maximum 10 mg) if the swelling is marked.
• Fungal: fluconazole 100 to 200 mg orally daily for 7 to 14 days in oropharyngeal candidiasis.
• Observation: admit if airway compromise, anaphylaxis, angioedema, severe pain with dehydration, or concern about deep neck infection; discharge when the swelling is resolving and the patient can swallow fluids.
• Refer to ENT for recurrent uvulitis, abscess, elongated uvula causing symptoms (uvulectomy), or hereditary angioedema evaluation to immunology.
• Advise to return immediately for noisy breathing, voice change, drooling or difficulty swallowing.