Case Presentation

A 65-year-old man presented to the immediate care clinic with a four-day history of sore throat. He had a stapedectomy five days prior under general anesthesia. In addition to a foreign body sensation and odynophagia, he felt that his throat would close up when he tried to sleep in a supine position. He denied any fevers, chills, orphonation problems. His vitals were a temperature of 37.8 degrees Celsius; heart rate of 80 beats per minute; blood pressure of 123/75 mm Hg; respiratory rate of 16 breaths per minute, and oxygen saturation of 96 percent on room air.

Figure 1: Uvular necrosis. (Click to enlarge.) (Images Dr. Nadeem)

Physical exam was notable for a swollen, erythematous demarcated uvula with a necrotic white tip (see figures 1 and 2). There was no uvula deviation, no peritonsillar elevation, and no swelling to other parts of the oral cavity. In addition, there was no lymphadenopathy. There was no accessory muscle use and no airway compromise. He had a normal ear, nose, and cardiopulmonary examination. A strep test was performed that was negative. Uvular necrosis is a rare complication of endotracheal intubation.¹

Medical Decision-Making

Figure 2: Uvular erythema and edema. (Click to enlarge.)

The differential for postoperative discomfort includes pharyngeal, uvular, laryngeal, and tracheal injuries. Due to the history of the stapedectomy, his medical records were reviewed including the operative report. It was determined that the patient was intubated for a significant time (about three hours). The physical exam revealed the white necrotic tip, which is classic for uvular necrosis after surgical procedure that required any throat instrumentation. The diagnosis of uvular necrosis was made.

Discussion

Throat pain from pharyngeal irritation is a common complaint after surgery requiring endotracheal intubation.² A thorough history and physical exam is vital in attaining the history of surgery and any throat procedures. The average duration of a sore throat postoperatively is around 16 hours. If symptoms are more than 24 hours and the pain is not responsive to over-the-counter pain medications, the pain might indicate uvular injury that warrants close attention.

As the symptoms develop one or two days after the injury to the uvula, the diagnosis may be seen in an urgent care or immediate care center rather than in the inpatient setting. Patients may complain of throat pain, foreign body sensation, gagging sensation, coughing, dysphagia, odynophagia, and in severe cases, shortness of breath from airway obstruction. Uvular necrosis should be considered, and the patient should have a very careful oropharyngeal examination. The examination usually reveals uvular edema and pharyngeal erythema. If necrosis is present, the distal part of the uvula may appear white.³

Uvular necrosis is believed to be caused by injury to blood vessels or compression of the lesser palatine artery and the surrounding vasculature supplying to the uvula by impingement of the uvula on the hard palate by oropharyngeal or nasopharyngeal devices. The uvula becomes flaccid during the induction of general anesthesia and prone to injury.⁵ Patients with elongated uvulas are also at increased risk of the uvula folding on itself and disrupting the blood supply distally. Prone positioning may also play a role as this can lead to a decrease in the space of the oropharyngeal area.

Risk factors include an elongated uvula, multiple oropharyngeal/nasopharyngeal instruments, obesity, prolonged surgery time, male gender, patient positioning, vigorous suctioning, and upper airway or gastroenterology procedures.^4,5 It has also been linked to placing endotracheal tubes in the midline during the intubation procedure. Figure 3 depicts the prone position of a patient intubated and shows how multiple pharyngeal devices can damage the uvula.

Figure 3: Patient intubated in prone position showing mechanism of uvular injury. (Click to enlarge.)

The diagnosis is clinical and based on clinical symptoms and a history of recent endotracheal intubation, upper endoscopy, or bronchoscopy. Treatment is reassurance, supportive care, steroids, and antihistamines. Antibiotics are optional but may be prescribed prophylactically to prevent an infection. If the patient presents with a fever and exudate, it is advisable to get laboratory testing, cultures, and treatment with antibiotics. Viscous lidocaine suspension and aluminum hydroxide/magnesium hydroxide can be used for pain control. In severe cases, surgical resection of the necrotic portions may be necessary.⁴

Typically, recovery lasts for two weeks, which entails sloughing of any necrotic portions of the uvula. Complications include airway obstruction, bleeding, or infection. In addition, the odynophagia may make nutrition and hydration difficult during the postoperative phase.

Preventative measures include decreasing suctioning, placing airway devices to the side of the midline during prolonged procedures, and using lower powered suction.

Disposition

As a courtesy, the otolaryngology team was consulted as they were the team that had done the stapedectomy. Treatment with a brief course of oral dexamethasone and amoxicillin was initiated, and supportive care was emphasized. At a follow-up visit a week later, there was no uvular erythema and the necrotic tissue had sloughed off. The patient had no further complaints about his throat.

Dr. Nadeem is an assistant professor of emergency medicine at the Stritch School of Medicine at Loyola University Medical Center in Maywood, IL.

References

1. Harris AM, Hicks LA, Quaseem A. Appropriate Antibiotics Use for Acute Respiratory Tract Infection in Adult: Advice for High-Value Care From the American College of Physicians and Centers for Disease Control and Prevention. 2016.
2. McHardy FE, Chung F. Post-operative sore throat: cause, prevention and treatment. Anaesthesia 1991; 54: 444-453.
3. Goldin M, Lynn J,. Uvular Necrosis, An Atypical Presentation of Sore Throat. Visual Diagnosis in Emergency Medicine. 2013; 44(1):185-186.
4. Calikapan GT, Karakus F,.Uvula necrosis after endotracheal intubation for rhinoplasty. Aesthetic Plastic Surgery 2008; 32: 710-711.
5. Smith Z, Lobo S. Uvular necrosis in an adolescent following general anaesthesia in the prone position. Anaesthesia Cases 2015;3: 7-11.