Uvulitis

Uvulitis is inflammation and swelling of the uvula, due to infection, allergy, angioedema, trauma, thermal injury or irritants, and it can threaten the airway if swelling is severe.

• Infectious causes: Group A Streptococcus, Haemophilus influenzae type b, viral pharyngitis, Epstein-Barr virus and Candida. In a child with uvulitis, check Haemophilus influenzae type b immunisation status.
• Non-infectious causes: hereditary or ACE-inhibitor angioedema, allergic reactions (food, drugs, insect stings), trauma (intubation, endoscopy, vomiting, snoring), thermal burns and chemical injury, smoking, cold-air exposure and dehydration.
• It is uncommon but can progress rapidly.
• Hereditary angioedema may involve the uvula without urticaria.

A swollen uvula produces throat symptoms.

• Sore throat, sensation of a lump, gagging, drooling, difficulty swallowing and muffled voice.
• Swollen, red (infection) or pale, translucent (allergy) uvula resting on the tongue.
• Fever, tonsillar exudate and cervical nodes suggest infection.
• Urticaria, wheeze, lip or face swelling and hypotension suggest anaphylaxis.
• Stridor, drooling, inability to swallow, and respiratory distress indicate airway compromise.
• Differential diagnosis: tonsillitis, peritonsillar abscess, epiglottitis, angioedema, anaphylaxis, retropharyngeal abscess, long uvula (elongated uvula), and diphtheria.
• Complications: airway obstruction, abscess, aspiration and spread of infection.

Diagnosis is clinical, with attention to airway and cause.

• Inspect the oropharynx gently, without a tongue depressor in a child with possible epiglottitis.
• Throat swab or rapid antigen test for Group A Streptococcus.
• Review recent drugs (ACE inhibitors), foods, stings and procedures.
• Complement C4 and C1 esterase inhibitor levels if recurrent angioedema without urticaria.
• Flexible nasendoscopy to assess the airway if concerned.
• Neck X-ray or computed tomography if abscess or epiglottitis suspected.

Secure the airway and treat the cause.

• Supportive: sit upright, humidified oxygen if needed, cold fluids or ice chips, analgesia, and monitor the airway closely. Admit those with airway symptoms.
• Pharmacological, infectious: phenoxymethylpenicillin 500 mg twice daily for 10 days (children 250 mg twice daily under 12 years), or amoxicillin. Intravenous ceftriaxone 50 to 100 mg/kg (adults 2 g) once daily for suspected Haemophilus influenzae type b or severe infection. Paracetamol 1 g every 6 hours.
• Allergic or anaphylactic: intramuscular adrenaline 0.5 mg (0.01 mg/kg in children, maximum 0.5 mg) of 1:1000 into the anterolateral thigh, repeated every 5 minutes if needed; chlorphenamine 10 mg (children 2.5 to 5 mg) intravenously or orally; hydrocortisone 200 mg intravenously (children 4 mg/kg); nebulised adrenaline 5 mL of 1:1000 for stridor.
• Dexamethasone 8 to 10 mg (children 0.15 to 0.6 mg/kg) once reduces swelling in non-allergic oedema.
• ACE-inhibitor angioedema: stop the drug permanently. Hereditary angioedema: C1 esterase inhibitor concentrate or icatibant 30 mg subcutaneously.
• Procedures: airway intervention (intubation, cricothyroidotomy or tracheostomy) for impending obstruction. Drainage of abscess.
• Special groups: children with a swollen uvula, fever and drooling need exclusion of epiglottitis.
• Red flags: stridor, drooling, voice change, respiratory distress, tongue or lip swelling, hypotension, trismus and rapid progression.
• Follow-up: review after 24 to 48 hours if discharged. Allergy testing for recurrent episodes. Provide adrenaline auto-injector if anaphylaxis.