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Uvula Necrosis, an Atypical Presentation of Sore Throat

      Case Report

      A 24-year-old man with no significant past medical history presented to the Emergency Department (ED) complaining of a sore throat and foreign body sensation, more with swallowing. He denied dysphagia, was a non-smoker, and had not had any recent respiratory illness.
      Two days prior, the patient had undergone endotracheal intubation for a left shoulder arthroscopy. The intubation had been performed easily for a Mallampati class I airway, with a Macintosh laryngoscopy blade number 3 and 8.0-mm endotracheal tube. The patient noticed mild sore throat soon after the procedure, which subsequently became severe throat pain and foreign body sensation the next morning after discharge. Despite oral anti-inflammatory and opioid analgesics, the pain persisted.
      Oropharyngeal examination revealed an elongated uvula with three well-demarcated regions: the base was erythematous and markedly edematous; the middle segment was pale pink and only mildly swollen; and the tip was white and ulcerated (Figure 1). The back of the uvula tip had a contused and translucent appearance (Figure 2).
      The impression in the ED was uvular necrosis vs. ulceration, possibly due to the endotracheal tube compressing/folding the patient’s baseline long uvula. An anesthesiologist consulted in the ED concurred the diagnosis was uvular necrosis. The patient was instructed to continue his regimen of pain medications, maintain a liquid or soft diet, and to return to the ED if his pain worsened or his breathing became compromised. The patient was also scheduled to follow-up at the Ear/Nose/Throat (ENT) clinic as an outpatient. The next day at home, the patient removed the ulcerated tip of the uvula with a pair of forceps, suffering mild bleeding. He immediately noted resolution of foreign body sensation. Over the course of the next week, the swelling and redness in the remaining uvular tissue gradually resolved without further intervention, as did the patient’s pain. The patient declined the ENT appointment.

      Discussion

      Sore throat after tracheal intubation is common. A study of 809 elective surgery patients revealed an incidence of 40%, though pain was generally mild to moderate and usually limited to<1 day (
      • Biro P.
      • Seifert B.
      • Pasch T.
      Complaints of sore throat after tracheal intubation: a prospective evaluation.
      ). In cases of sore throat that are persistent and more severe, uvular necrosis should be considered, and patients should undergo a careful oropharyngeal examination.
      Recent literature suggests that the musculus uvulae functions to maximize midline soft palate and posterior pharyngeal (velopharyngeal) contact. To produce most sounds, the air and sound need to be directed into the mouth and blocked from entering the nasal cavity by closing the velopharyngeal valve. In severe cases of velopharyngeal insufficiency, one can expect to phonate more nasal sound during speech, or weaker consonants due to inadequate air pressure in the mouth; however, most would hardly notice the difference (
      • Huang M.H.
      • Lee S.T.
      • Rajendran K.
      Structure of the musculus uvulae: functional and surgical implications of an anatomic study.
      ).
      Uvular necrosis is thought to result from compression of blood supply to the uvula. Ulceration or necrosis of the uvula has been reported after tracheal intubation as well as endoscopic procedures, and has also been linked to forceful suctioning and placement of the endotracheal tube in the midline (
      • Tang S.J.
      • Kanwal F.
      • Gralnek I.M.
      Uvular necrosis after upper endoscopy: a case report and review of the literature.
      ,
      • Gupte A.R.
      • Draganov P.V.
      Post-endoscopic retrograde cholangiopancreatography uvular necrosis.
      ,
      • Nijjer S.
      • Crean A.
      • Li W.
      • Swan L.
      Uvular ulceration following transoesophageal echocardiography.
      ,
      • Harris M.A.
      • Kumar M.
      A rare complication of endotracheal intubation.
      ). In this patient, it is possible that the uvula, which the patient reports was fairly long at baseline, became folded over itself, thus mechanically disrupting blood supply distally. The clear demarcation between the necrotic and healthy portions of the uvula supports this hypothesis, which has been suggested in earlier case reports (
      • Krantz M.A.
      • Solomon D.L.
      • Poulos J.G.
      Uvular necrosis following endotracheal intubation.
      ). Reported treatments have ranged from observation to intravenous steroids, antihistamines, antibiotics, or topical adrenaline (
      • Atkinson C.J.
      • Rangasami J.
      Uvula necrosis—an unusual cause of severe postoperative sore throat.
      ). Another approach worth considering is immediate surgical amputation of the ulcerated region in the ED, which is what our patient chose to do at home. Although this treatment may minimize foreign body sensation, it is unlikely to relieve painful inflammation of the remaining uvular tissue. Considering that complete recovery usually occurs within days to a few weeks, we recommend observation.

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