What are the treatment options for a swollen uvula, potentially caused by an allergic reaction or bacterial infection, in a patient with a history of allergic reactions or asthma?

Treatment of Swollen Uvula (Uvulitis)

Immediately administer intramuscular epinephrine 0.3-0.5 mg (adults) or 0.01 mg/kg (children, max 0.3 mg) if there is any evidence of airway compromise, respiratory symptoms, or signs of anaphylaxis, as this is a potentially life-threatening condition that requires urgent intervention. 1, 2

Initial Assessment and Risk Stratification

When evaluating a patient with uvular swelling, rapidly assess for:

• Respiratory compromise: wheezing, stridor, dyspnea, throat tightness, difficulty swallowing, persistent cough, or sensation of airway narrowing 2, 3
• Cardiovascular symptoms: hypotension, tachycardia, syncope, dizziness, pallor 2
• Associated allergic features: urticaria, angioedema elsewhere, gastrointestinal symptoms (persistent crampy abdominal pain, vomiting, diarrhea) 2, 4
• Severity of uvular edema: degree of airway narrowing on direct visualization 5, 3

The presence of any respiratory symptoms or rapidly progressive swelling mandates immediate epinephrine administration—do not wait for complete airway obstruction to develop 1, 2, 3.

Immediate Management Algorithm

For Allergic/Anaphylactic Presentation (with respiratory symptoms, urticaria, or known allergen exposure):

1. Epinephrine first-line: 0.3-0.5 mg IM (adults) or 0.01 mg/kg IM (children) in the anterolateral thigh 1, 2

   • This is the only effective treatment for anaphylaxis and should never be delayed 1, 2
   • Fatal reactions are associated with delayed epinephrine administration 1, 2

2. Adjunctive medications (after epinephrine, not instead of):

   • H1-antihistamine: diphenhydramine 25-50 mg IV/oral (adults) or 1-2 mg/kg (children) 1, 2
   • H2-antihistamine: ranitidine 1-2 mg/kg or famotidine 1, 2
   • Corticosteroids: methylprednisolone IV or prednisone 1 mg/kg oral (max 60-80 mg) to prevent biphasic reactions 1, 5, 3

3. Supportive care:

   • Position supine with legs elevated (unless respiratory distress present) 2
   • Supplemental oxygen as needed 2
   • IV fluid bolus (Ringer's lactate 10-20 mL/kg) if hypotensive 1
   • Inhaled albuterol if wheezing present 2

For Idiopathic/Non-Allergic Presentation (isolated uvular swelling without systemic symptoms):

If there is no respiratory compromise and the presentation appears idiopathic (more common in overweight patients who snore) 4:

• Corticosteroids: methylprednisolone IV or oral prednisone 6
• Antihistamines: diphenhydramine and H2-blocker 6
• Close airway monitoring, as progression can occur 7

However, maintain a low threshold for epinephrine if any respiratory symptoms develop, as isolated uvulitis can rapidly progress to life-threatening airway obstruction 5, 7.

Special Considerations for Patients with Asthma History

Patients with asthma and allergic reactions are at higher risk for severe anaphylaxis 4. In these patients:

• Administer epinephrine even more promptly at the first sign of respiratory involvement 1
• Ensure adequate asthma control medications are continued 8
• Consider earlier airway intervention if edema is progressive 3, 7

Critical Pitfalls to Avoid

• Never rely on antihistamines alone for uvular swelling with any respiratory symptoms—they are ineffective for anaphylaxis and have dangerously slow onset 1, 2
• Do not delay epinephrine to give antihistamines or corticosteroids first in cases with airway involvement 1, 2
• Do not misdiagnose as simple pharyngitis and inappropriately prescribe only antibiotics 1
• Do not underestimate progression risk: even isolated uvulitis can rapidly evolve to complete airway obstruction 7

Etiologic Investigation

After stabilization, investigate potential causes 4:

• Allergic triggers: foods (especially peanuts), medications, insect stings to the oropharynx 5, 4, 3
• Inhalational exposures: cannabis, irritants 6
• Mechanical factors: snoring, obesity (predispose to idiopathic uvulitis) 4

Patients should undergo allergy testing for drugs, airborne allergens, and foods, particularly if urticaria or angioedema accompanied the uvulitis 4.

Post-Treatment Management

• Observe for biphasic reactions: monitor for at least 4-6 hours after symptom resolution 1
• Prescribe epinephrine auto-injector (2 doses) if allergic etiology confirmed, with proper training 1
• Provide allergen avoidance education and anaphylaxis emergency action plan 1
• Refer to allergist for proper allergen identification and consideration of immunotherapy if appropriate 1