What are the differential diagnoses and treatment guidelines for swelling/erythema of the uvula?

Differential Diagnosis and Management of Uvular Swelling/Erythema

Immediate Life-Threatening Considerations

When a patient presents with uvular swelling and erythema, immediately assess for anaphylaxis or epiglottitis, as these conditions can rapidly progress to complete airway obstruction and death. 1

Anaphylaxis Assessment

• Look for accompanying signs: generalized urticaria, respiratory compromise (wheeze, stridor, dyspnea), hypotension, or gastrointestinal symptoms (cramping, vomiting) occurring within minutes to hours of allergen exposure 2
• Swollen lips-tongue-uvula combined with respiratory symptoms or reduced blood pressure meets diagnostic criteria for anaphylaxis 2
• Administer intramuscular epinephrine 0.01 mg/kg (max 0.5 mg adult, 0.3 mg child) immediately to the anterolateral thigh if anaphylaxis is suspected—do not delay for antihistamines or corticosteroids alone 1, 2
• Provide supplemental oxygen (6-8 L/minute), establish IV access, and give 1-2 liters normal saline rapidly 1, 2
• Observe for at least 4-6 hours as biphasic reactions can occur up to 72 hours later 2, 1

Epiglottitis Evaluation

• Check for fever, severe dysphagia, drooling, muffled voice, and respiratory distress 1
• If suspected, do not manipulate the airway and prepare for emergent airway management 1

Primary Differential Diagnoses

1. Infectious Uvulitis

Group A Streptococcal Pharyngitis

• Classic presentation: sudden onset severe sore throat, fever, tender anterior cervical lymph nodes, tonsillopharyngeal exudates, palatal petechiae, and beefy red swollen uvula WITHOUT cough 3, 4
• The presence of viral features (cough, rhinorrhea, conjunctivitis, hoarseness, diarrhea) argues strongly against GAS and testing should not be performed 3, 4
• Microbiological confirmation is mandatory—perform rapid antigen detection test (RADT) and/or throat culture 3
• In children/adolescents, negative RADT must be backed up by throat culture; in adults, negative RADT alone is sufficient 3
• First-line treatment: penicillin or amoxicillin for 10 days to prevent acute rheumatic fever and post-streptococcal glomerulonephritis 3
• For penicillin-allergic patients: first-generation cephalosporin, clindamycin, clarithromycin, or azithromycin 3

Haemophilus influenzae Type B Uvulitis

• Rare but serious bacterial infection causing isolated uvulitis with bacteremia 5
• Obtain lateral neck radiograph and initiate parenteral antibiotics if suspected 5

Arcanobacterium haemolyticum

• Consider in teenagers/young adults with pharyngitis and scarlatiniform rash when GAS testing is negative 3

2. Allergic/Angioedema (Non-Anaphylactic)

Isolated Uvulitis from Angioedema

• Presents as isolated uvular swelling without systemic symptoms 1, 6
• Treatment: oral antihistamines (diphenhydramine or cetirizine), analgesics (NSAIDs or acetaminophen), cold compresses, and oral hydration 1
• Do not prescribe antibiotics empirically—most cases are due to angioedema, trauma, or allergic reactions and do not require antimicrobials 1
• Monitor closely for progression to airway compromise 6, 7

Hymenoptera Sting to Uvula

• Direct sting causes local inflammation and edema with potential for rapid airway obstruction 8
• Immediately remove stinger manually with tweezers 8
• Administer epinephrine if significant upper airway edema develops, along with IV corticosteroids and antihistamines 8

3. Viral Upper Respiratory Infection

• Most common cause when cough accompanies pharyngitis symptoms 4
• Viral causes include rhinovirus, coronavirus, adenovirus, influenza, parainfluenza, RSV, EBV, and enteroviruses 4
• No antibiotics indicated—provide symptomatic treatment with analgesics, antipyretics, and supportive care 4
• Expected duration 5-7 days, may persist up to 10 days 4

4. Trauma-Related Uvulitis

• Can result from thermal injury, mechanical trauma, or irritation 6, 7
• Treat symptomatically with analgesics and observation 1

5. Severe Cutaneous Adverse Reactions (SCAR)

• Stevens-Johnson syndrome/toxic epidermal necrolysis can present with mucosal involvement including uvular erythema and edema 2
• Look for target lesions, purpuric macules, blisters, epidermal detachment, and involvement of other mucosal sites (eyes, genitals) 2
• Discontinue any potential culprit drug immediately and consider urgent dermatology consultation 2

Clinical Decision Algorithm

1. First: Rule out airway emergency

   • Assess for stridor, respiratory distress, drooling, inability to swallow 1, 6
   • If present: prepare for airway management, administer epinephrine if anaphylaxis suspected 1

2. Second: Assess for anaphylaxis criteria

   • Sudden onset with skin/mucosal involvement PLUS respiratory compromise or hypotension 2
   • OR two or more systems involved (skin, respiratory, GI, cardiovascular) after allergen exposure 2
   • If yes: epinephrine first, then adjunctive antihistamines and corticosteroids 1

3. Third: Evaluate for infectious etiology

   • Apply Modified Centor Criteria: fever, tonsillar exudates, tender anterior cervical adenopathy, absence of cough 4
   • If viral features present (cough, rhinorrhea, conjunctivitis): no testing or antibiotics needed 3, 4
   • If bacterial features present: perform RADT/throat culture and treat confirmed GAS with penicillin or amoxicillin for 10 days 3

4. Fourth: If isolated uvulitis without systemic features

   • Treat with oral antihistamines, analgesics, and supportive care 1
   • Monitor for progression over 4-6 hours 1

Critical Pitfalls to Avoid

• Never delay epinephrine in suspected anaphylaxis—antihistamines and corticosteroids are adjuncts only and do not prevent airway compromise or cardiovascular collapse 1
• Do not test for GAS when viral features (especially cough) are present, as this leads to unnecessary antibiotic use 3, 4
• Do not prescribe antibiotics empirically for non-infectious uvulitis 1
• Always examine the epiglottis and other upper airway structures, as isolated uvular involvement may progress to involve adjacent structures 6
• In children with negative RADT, always obtain confirmatory throat culture before withholding antibiotics 3