What is the best course of treatment for a swollen uvula?

Treatment of Swollen Uvula

For isolated uvulitis without signs of anaphylaxis or epiglottitis, treat with oral antihistamines (diphenhydramine or cetirizine), analgesics (NSAIDs or acetaminophen), cold compresses, and oral hydration—most cases resolve without antibiotics and have a benign course. 1, 2

Initial Assessment: Rule Out Life-Threatening Conditions

Before treating isolated uvulitis, you must immediately assess for two critical conditions:

Anaphylaxis

• Look for accompanying respiratory compromise, skin manifestations (urticaria, flushing), hypotension, or gastrointestinal symptoms 1
• If anaphylaxis is present, administer epinephrine immediately—antihistamines and corticosteroids are adjuncts only and do not prevent airway compromise or cardiovascular collapse 1
• Provide supplemental oxygen and establish IV access 1
• Administer antihistamines and corticosteroids as adjunctive therapy only after epinephrine 1
• Observe for at least 4-6 hours as biphasic reactions can occur 1

Epiglottitis

• Check for fever, severe dysphagia, drooling, muffled voice, and respiratory distress 1, 3
• Obtain a lateral neck radiograph to rule out epiglottitis in all patients with acute uvulitis 3, 4
• This is critical: uvulitis can occur in combination with epiglottitis, which is life-threatening 3
• If epiglottitis is present, initiate parenteral antibiotics and consider airway management in the ICU 3, 4

Treatment of Isolated Uvulitis (Non-Infectious)

Once you've excluded anaphylaxis and epiglottitis, most cases of isolated uvulitis are benign and self-limited 2:

First-Line Symptomatic Treatment

• Oral antihistamines: diphenhydramine or cetirizine to reduce edema 1
• Analgesics: NSAIDs or acetaminophen for pain control 1
• Cold compresses and oral hydration for comfort 1
• Consider sympathomimetic drugs (epinephrine by injection or β-agonists by inhalation) for rapid resolution in cases causing significant airway-related symptoms 5

What NOT to Do

• Do not prescribe antibiotics empirically for non-infectious uvulitis—most cases are due to angioedema, trauma, or allergic reactions and do not require antimicrobials 1
• In a series of 15 patients with uvulitis, 50% received symptomatic treatment only with excellent outcomes, and 93% required no further care after discharge 2

When to Consider Infectious Etiology

Bacterial Uvulitis (Rare)

• Consider if uvulitis is associated with tonsillopharyngeal erythema, exudates, fever, and tender anterior cervical lymph nodes 6, 7
• However, visual findings alone cannot differentiate bacterial from viral causes—microbiological confirmation is required 6
• Haemophilus influenzae type b can cause isolated bacteremic uvulitis, particularly in children 4
• If bacterial infection is suspected based on systemic signs (fever, bacteremia), initiate parenteral antibiotics after obtaining cultures 4

Associated Peritonsillar Abscess

• Check for tonsillar asymmetry, which may indicate developing peritonsillar abscess 6
• This is the only complication in the largest uvulitis series that required hospital admission 2

Clinical Course and Follow-Up

• Most cases of isolated uvulitis have a relatively benign course with no significant airway or infectious complications 2
• Symptoms predominantly involve sore throat and dysphagia 2
• Resolution typically occurs within hours to days with symptomatic treatment 2, 5
• Airway obstruction is possible but uncommon—maintain a high index of suspicion and monitor for worsening symptoms 8, 5

Common Pitfalls to Avoid

• Do not assume all uvular swelling is benign—always examine for epiglottitis with lateral neck radiograph 3, 4
• Do not delay epinephrine if anaphylaxis is present—antihistamines alone are insufficient 1
• Do not prescribe antibiotics without evidence of bacterial infection—most cases are non-infectious 1, 2
• Ensure complete visualization of the oropharynx to assess for associated tonsillar pathology or asymmetry 6