Images in Emergency Medicine
Article Outline
A 44-year-old white man presented after transfer from an outside emergency department (ED) with 6 hours of sore throat. He awoke the morning of his presentation with the sensation of something “stuck” in the back of his throat. Patient had a medical history of hypertension that was not currently treated with medications. Physical examination was significant for a muffled voice and occasional gagging as a result of a swollen, edematous structure in the posterior oropharynx. Patient had no fever, drooling, pain with tongue elevation, or lymphadenopathy. The initial oral examination is shown in the Figure.
Figure.
Oropharyngeal examination of a 44-year-old patient presenting with chief complaint of sore throat. (Patient consent obtained before photography.) Used with permission of Mark D. Lopez, MD, Department of Emergency Medicine, Medical College of Georgia, Augusta, GA.
Diagnosis
Uvular angioedema (Quincke’s disease)
The figure demonstrates isolated angioedema of the uvula. Patient had no history of similar episodes and no family history of angioedema. Further questioning revealed that the patient had been treated recently and was receiving amoxicillin for a tooth infection. No leukocytosis (WBC 4.1×103) or fever was present.
The patient was admitted to the otolaryngologic service and treated with diphenhydramine, famotidine, and dexamethasone. He was also treated empirically with antibiotics (clindamycin). A bedside nasopharyngeal scope revealed a normal epiglottis and vocal cords, with significant uvular edema. Patient’s hospital course was uncomplicated, and he was discharged 36 hours later.
Quincke first characterized angioedema in the medical literature in 1882.1 Since that time, isolated angioedema of the uvula has been termed Quincke’s disease. Several causes of uvular swelling have been described, including hereditary angioedema, trauma, inhalation exposure, medication reactions, and infectious causes. Isolated uvular angioedema is usually caused by a type I hypersensitivity reaction.2 This should be differentiated from uvulitis, which is infectious and frequently has concomitant epiglottitis.3
Maintaining the airway is the primary management strategy in Quincke’s disease. Treatment in the ED consists of intravenous H1 and H2 histamine blockers, corticosteroids, and infrequently epinephrine. More invasive (surgical) techniques such as needle decompression and uvulectomy should be performed with the involvement of otolaryngology consultants.4
References
- . Uber akutes umschreibnes Hautodem. Monatschr Prakt Dermatol. 1882;1:129–131
- . Isolated uvular angioedema in a teenage boy. Internet J Emerg Med. 2007;3;Accessed May 20, 2007
- Isolated uvulitis: an uncommon but not rare clinical entity. Indian J Otolaryngol Head Neck Surg. 2005;57:139–140
- . Isolated uvular angioedema associated with ace inhibitor use. J Emerg Med. 1995;13:327–330
For the diagnosis and teaching points, see page 12.
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PII: S0196-0644(07)00614-2
doi:10.1016/j.annemergmed.2007.05.017
© 2008 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
