Isolated uvulitis.

A 46-year-old woman presented to the emergency department with an 8-hour history of progressive throat pain, dysphagia, and odynophagia. Of note, she had begun her day by taking a magnesium oxide supplement for the first time. She reported no fever, chills, shortness of breath, trauma, or recent upper respiratory tract infection. Her medical history was significant for asthma, hypertension, and mitral valve prolapse. She also recalled an episode of acute tongue swelling during childhood.

On physical examination, the patient was alert and in no distress. Her voice had a "hot potato" quality to it, but she exhibited no drooling or stridor. Examination of the oral cavity revealed an edematous uvula with erythema extending toward the soft palate and superior tonsillar pillars (figure). No tenderness of the peritonsillar tissue was noted, but tender cervical adenopathy was observed bilaterally. No supraglottic inflammation was noted on flexible laryngoscopy. Findings on laboratory investigations were significant for an elevated white blood cell count of 16,300/ [mm.sup.2] (normal: 4,500 to 11,000) with 95% neutrophils (normal: 41 to 85%). Levels of complement C3 and C4 were elevated.

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A diagnosis of isolated uvulitis was made, and the patient was admitted for airway observation and empiric treatment with methylprednisolone, ranitidine, ciprofloxacin, and metronidazole (she was allergic to penicillin, clindamycin, macrolides, and sulfa-containing drugs). The uvulitis resolved slowly, and the patient was discharged after 3 days. At the 1-week follow-up visit, she was asymptomatic.

Isolated uvulitis is an uncommon clinical entity, as fewer than 30 cases have been reported in the literature. (1,2) Uvular edema can be a consequence of trauma, chemical irritation, infection, neoplasm, or angioedema of either immunologic or nonimmunologic mechanisms. (3) The clinical manifestations of uvular edema may include dysphagia, a globus sensation, gagging, and a muffled voice. Uvulitis secondary to viral or bacterial infection is usually also associated with odynophagia, throat pain, and fever, and it will typically manifest with an inflammatory appearance. (4) An angioedematous uvula is usually not erythematous; it resembles a large, white grape. (5)

In view of the known association between uvulitis and epiglottitis, the workup of uvulitis should include laryngoscopy. (6-8) The initial laboratory workup is limited, including only a complete blood count with differential and a complement C4 level. Eosinophilia suggests an allergic reaction as the cause, whereas a low complement C4 level suggests hereditary angioedema. Initial management should always include an airway assessment. Intravenous access should be obtained for blood draws and administration of intravenous medications. Treatment is tailored to the suspected etiology; this may involve [H.sub.1] and [H.sub.2] blockers, steroids, antibiotics, and/or uvular decompression. (9)

References

(1.) Guarisco JL, Cheney ML, LeJeune FE, Reed HT. Isolated uvulitis secondary to marijuana use. Laryngoscope 1988; 98(12): 1309-12.

(2.) Lathadevi HT, Karadi RN, Thobbi RV, et al. Isolated uvulitis: An uncommon but not a rare clinical entity. Indian Journal of Otolaryngology Head and Neck Surgery 2005; 57(2): 139-40.

(3.) Evans TC, Roberge RJ. Quincke's disease of the uvula. Am J Emerg Med 1987; 5(3): 211-16.

(4.) Rapkin RH. Simultaneous uvulitis and epiglottitis. JAMA 1980; 243(18): 1843.

(5.) Reddy CR, Margolin SJ. Acute uvular edema. Am J Dis Child 1983; 137(12): 1204-5.

(6.) McNamara R, Koobatian T. Simultaneous uvulitis and epiglottitis in adults. Am J Emerg Med 1997; 15(2): 161-3.

(7.) Westerman EL, Hutton JR Acute uvulitis associated with epiglottitis. Arch Otolaryngol Head Neck Surg 1986; 112(4): 448-9.

(8.) Short DG, Kitain DS. Acute uvulitis in combination with acute epiglottitis: A case presentation. Ear Nose Throat J 1991; 70(7): 458-60.

(9.) Goldberg R, Lawton R, Newton E, Line WS. Evaluation and management of acute uvular edema. Ann Emerg Med 1993; 22(2): 251-5.

Marc Cohen, MD; Dinesh K. Chhetri, MD; Christian Head, MD

From the Division of Head and Neck Surgery, Department of Surgery, UCLA Medical Center, University of California, Los Angeles.