- Email: [email protected]
Treatment of an enlarged uvula
Available online at www.sciencedirect.com
British Journal of Oral and Maxillofacial Surgery 46 (2008) 490–491
Short communication
Treatment of an enlarged uvula Leo H.H. Cheng ∗ , Deane Halfpenny Oral and Maxillofacial Surgery and Anaesthesia, Homerton University NHS Trust, Homerton Row, London, E9 6SR, United Kingdom Accepted 26 November 2007 Available online 1 February 2008
Abstract We report a case of enlarged uvula (5.5 cm) that caused difficulty in swallowing and speech after it had been damaged by intubation or suction of the throat. Medical treatment failed, so 4.5 cm was resected by diathermy. The patient made an uneventful recovery. © 2007 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Uvula; Uvulectomy; Endotracheal intubation
Introduction
Case report
Uvulectomy with laser or diathermy has been welldocumented as part of uvulopalatopharyngoplasty in the treatment of snoring.1–2 Uvulectomy in children is traditional in several sub-Saharan African countries where it is done by barbers, and serious complications have been reported.3–4 Uvulitis that causes upper airway distress has led to emergency uvulectomy.5 There was also a report of a uvular tip that sloughed off without complications 10 days after insertion of a laryngeal airway for a diagnostic laparoscopy; there had been no report of difficulty in intubation.6 We report a case of an enlarged uvula that had been caused by intubation or suction and caused discomfort with swallowing and speech. Conservative treatment failed and the patient had an uvulectomy.
A 25-year-old man had arthroscopy of his shoulder for recurrent dislocation as a day case. He was intubated with a reinforced endotracheal tube. Before extubation vigorous suction was applied to the back of the throat and there were minimal secretions. He was given routine nursing care postoperatively and was allowed home after observation. He contacted the ward later complaining of increasing discomfort in the throat, and he felt as if there was “a worm at the back of his mouth”. His soft palate was inflamed and his uvula was enlarged, ulcerated, and oedematous and lying on the dorsum of the tongue towards the junction of the anterior twothirds and the posterior third (Fig. 1). Adrenaline (1 in 1000) 2 mg in 5ml normal saline was given by nebuliser, and dexamethosone 10 mg intramuscularly, but no antibiotics. Although the inflammation of the soft palate subsided and the enlarged uvula reduced in size after 24 hours of medical treatment and bed rest, his uvula remained elongated measuring 5.5 × 1.5 cm. There were several ulcers on the uvular mucosa that caused discomfort when swallowing or speaking. There was a risk of sloughing of the ulcers on the surface of the uvula, which might dislodge the uvula with the potential to block his airway.
∗ Corresponding author. Oral and Maxillofacial Surgery, 5th Floor, King George V Building, St Bartholomew’s Hospital, West Smithfield, London, WC1A 7BE, United Kingdom. Tel.: +44 020 7377 7000 x 2102; fax: +44 020 7601 8484. E-mail address: [email protected] (L.H.H. Cheng).
0266-4356/$ – see front matter © 2007 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2007.11.019
L.H.H. Cheng, D. Halfpenny / British Journal of Oral and Maxillofacial Surgery 46 (2008) 490–491
Fig. 1. Enlarged uvula resting on the dorsum of the tongue.
A 4.5 cm uvula was therefore excised with diathermy under a general anaesthesia with nasotracheal intubation. Histological examination showed abscesses and ulcers on the mucosa of the uvula. The patient had instant relief and he regained the normal functions of swallowing and speech shortly after the operation. He made a complete recovery and later had a further operation on his shoulder with uneventful intubation and extubation and no problems with his remaining uvula.
Discussion The size of the uvula (5.5 × 1.5 cm) after reduction of the oedema with adrenaline and steroids is unusual. It was even longer and wider than those of 121 habitual snorers (12.2 (3) × 7.3 (1) mm) who were compared with 51 non-snorers (10.2 (3) × 6.4 (1) mm).2
491
Intubation for investigative and surgical procedures is routine in day case surgery. Despite smooth and uncomplicated intubation using either a laryngeal mask or a normal or a reinforced endotracheal tube, injury to the uvula by either during intubation or extubation, or by suction to the back of throat before extubation is a possible cause of uvular enlargement. Normal function of the throat can be affected, particularly during swallowing and speech. In more severe cases, uvulitis and cellulitis can cause acute airway obstruction that necessitates emergency uvulectomy.5 Medical treatment with systemic steroids and local adrenaline help to reduce the inflammation of the soft palate and uvula, in most cases. However, if the risk of uvular detachment with potential airway blockage arises, we advocate early uvulectomy after a trial of medical treatment.
References 1. Ellis PD, Williams JE, Shneerson JM. Surgical relief of snoring due to palatal flutter: a preliminary report. Ann R Coll Surg Engl 1993;75:286–90. 2. Reda M, Sims AJ, Collins, et al. Morphological assessment of the soft palate in habitual snoring using image analysis. Larynogoscope 1999;109:1655–60. 3. Prual A, Gamatie Y, Djakounda M, Huguet D. Traditional uvulectomy in Niger: a public health problem? Soc Sci Med 1994;39:1077–82. 4. Hartley BE, Rowe-Jones J. Uvulectomy to prevent throat infections. J Laryngol Otol 1994;108:65–6. 5. Hawke M, Kwok P. Acute inflammatory edema of the uvula (uvulitis) as a cause of respiratory distress: a case report. J Otolaryngol 1987;16:188–90. 6. Bennett AMD, Badia L. Minerva. BMJ 2003;326:940.
British Journal of Oral and Maxillofacial Surgery 46 (2008) 490–491
Short communication
Treatment of an enlarged uvula Leo H.H. Cheng ∗ , Deane Halfpenny Oral and Maxillofacial Surgery and Anaesthesia, Homerton University NHS Trust, Homerton Row, London, E9 6SR, United Kingdom Accepted 26 November 2007 Available online 1 February 2008
Abstract We report a case of enlarged uvula (5.5 cm) that caused difficulty in swallowing and speech after it had been damaged by intubation or suction of the throat. Medical treatment failed, so 4.5 cm was resected by diathermy. The patient made an uneventful recovery. © 2007 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Uvula; Uvulectomy; Endotracheal intubation
Introduction
Case report
Uvulectomy with laser or diathermy has been welldocumented as part of uvulopalatopharyngoplasty in the treatment of snoring.1–2 Uvulectomy in children is traditional in several sub-Saharan African countries where it is done by barbers, and serious complications have been reported.3–4 Uvulitis that causes upper airway distress has led to emergency uvulectomy.5 There was also a report of a uvular tip that sloughed off without complications 10 days after insertion of a laryngeal airway for a diagnostic laparoscopy; there had been no report of difficulty in intubation.6 We report a case of an enlarged uvula that had been caused by intubation or suction and caused discomfort with swallowing and speech. Conservative treatment failed and the patient had an uvulectomy.
A 25-year-old man had arthroscopy of his shoulder for recurrent dislocation as a day case. He was intubated with a reinforced endotracheal tube. Before extubation vigorous suction was applied to the back of the throat and there were minimal secretions. He was given routine nursing care postoperatively and was allowed home after observation. He contacted the ward later complaining of increasing discomfort in the throat, and he felt as if there was “a worm at the back of his mouth”. His soft palate was inflamed and his uvula was enlarged, ulcerated, and oedematous and lying on the dorsum of the tongue towards the junction of the anterior twothirds and the posterior third (Fig. 1). Adrenaline (1 in 1000) 2 mg in 5ml normal saline was given by nebuliser, and dexamethosone 10 mg intramuscularly, but no antibiotics. Although the inflammation of the soft palate subsided and the enlarged uvula reduced in size after 24 hours of medical treatment and bed rest, his uvula remained elongated measuring 5.5 × 1.5 cm. There were several ulcers on the uvular mucosa that caused discomfort when swallowing or speaking. There was a risk of sloughing of the ulcers on the surface of the uvula, which might dislodge the uvula with the potential to block his airway.
∗ Corresponding author. Oral and Maxillofacial Surgery, 5th Floor, King George V Building, St Bartholomew’s Hospital, West Smithfield, London, WC1A 7BE, United Kingdom. Tel.: +44 020 7377 7000 x 2102; fax: +44 020 7601 8484. E-mail address: [email protected] (L.H.H. Cheng).
0266-4356/$ – see front matter © 2007 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2007.11.019
L.H.H. Cheng, D. Halfpenny / British Journal of Oral and Maxillofacial Surgery 46 (2008) 490–491
Fig. 1. Enlarged uvula resting on the dorsum of the tongue.
A 4.5 cm uvula was therefore excised with diathermy under a general anaesthesia with nasotracheal intubation. Histological examination showed abscesses and ulcers on the mucosa of the uvula. The patient had instant relief and he regained the normal functions of swallowing and speech shortly after the operation. He made a complete recovery and later had a further operation on his shoulder with uneventful intubation and extubation and no problems with his remaining uvula.
Discussion The size of the uvula (5.5 × 1.5 cm) after reduction of the oedema with adrenaline and steroids is unusual. It was even longer and wider than those of 121 habitual snorers (12.2 (3) × 7.3 (1) mm) who were compared with 51 non-snorers (10.2 (3) × 6.4 (1) mm).2
491
Intubation for investigative and surgical procedures is routine in day case surgery. Despite smooth and uncomplicated intubation using either a laryngeal mask or a normal or a reinforced endotracheal tube, injury to the uvula by either during intubation or extubation, or by suction to the back of throat before extubation is a possible cause of uvular enlargement. Normal function of the throat can be affected, particularly during swallowing and speech. In more severe cases, uvulitis and cellulitis can cause acute airway obstruction that necessitates emergency uvulectomy.5 Medical treatment with systemic steroids and local adrenaline help to reduce the inflammation of the soft palate and uvula, in most cases. However, if the risk of uvular detachment with potential airway blockage arises, we advocate early uvulectomy after a trial of medical treatment.
References 1. Ellis PD, Williams JE, Shneerson JM. Surgical relief of snoring due to palatal flutter: a preliminary report. Ann R Coll Surg Engl 1993;75:286–90. 2. Reda M, Sims AJ, Collins, et al. Morphological assessment of the soft palate in habitual snoring using image analysis. Larynogoscope 1999;109:1655–60. 3. Prual A, Gamatie Y, Djakounda M, Huguet D. Traditional uvulectomy in Niger: a public health problem? Soc Sci Med 1994;39:1077–82. 4. Hartley BE, Rowe-Jones J. Uvulectomy to prevent throat infections. J Laryngol Otol 1994;108:65–6. 5. Hawke M, Kwok P. Acute inflammatory edema of the uvula (uvulitis) as a cause of respiratory distress: a case report. J Otolaryngol 1987;16:188–90. 6. Bennett AMD, Badia L. Minerva. BMJ 2003;326:940.