Larry Mellick, MD, MS, FAAP, FACEP
Professor of Emergency Medicine
Medical College of Georgia

Pearl: Marked swelling of the uvula is associated with marijuana smoking.

Presentation: A 26-year-old male presented to the emergency department following an assault. He admitted to being intoxicated with alcohol and smoking marijuana. During the assault, he was hit in the head with a board and was kicked multiple times. He reported a period of being unconscious and complained of pain in the neck, low back, left wrist, and ankle.

The patient was awake and alert. Besides the impressive number of body tattoos, his examination was most notable for periorbital edema, dried blood on his face and nares, and a markedly swollen and edematous uvula. (See Figure 1.)

The CT scan of the head and neck showed no evidence of injury other than soft-tissue swelling. His alcohol level was 122 mg/dl, and the urine drug screen was positive for benzodiazepines, cocaine, opiates, and marijuana. The patient was administered morphine and ketorolac intravenously for pain as well as dexamethasone (10 mg) IV for the swollen epiglottis. Despite having pulled out his intravenous line, the alert and oriented patient was considered competent to be discharged at his insistence and against medical advice.

Discussion: The occurrence of uvula swelling following marijuana smoking has been described previously.^1,2,3 The differential diagnosis of uvula swelling includes infections with Group A Streptococcus, Hemophilus influenza type B, trauma, allergic reactions, and angioedema associated with the use of ACE inhibitors or hereditary angioedema and C1 esterase inhibitor deficiency. Besides infections and allergic reactions, anesthesia-related deep sedation, airway instrumentation, and intubations also have been associated with swelling of the uvula.⁴ Less commonly, and as observed in this patient, uvular swelling can occur following marijuana smoking. The mechanism of mucosal injury is thought to be secondary to the hot gases that occur when marijuana is smoked in a pipe or water pipe.⁵

Management of uvular swelling depends somewhat on its etiology. If an allergic etiology is suspected, H1 and H2 histamine blockers, parenteral epinephrine, and corticosteroids are appropriate. If an infectious cause is more likely, antibiotics appropriate for the most likely infectious agent should be administered. In this case, the cause of mucosal injury was heated gases. Intravenous dexamethasone was administered as well as the non-steroidal anti-inflammatory drug (NSAID) ketorolac.

Finally, the clinician should remember that there is an association between infections of the uvula and the epiglottis.⁶ Additional investigations for an associated infection of the epiglottis should be considered when the setting and presentation suggest that possibility.

References:

1. Mallat AM, Roberson J, Brock-Utne JG. Preoperative marijuana inhalation: an airway concern. Can J Anaesth 1996;43:691–693.
2. Guarisco JL, Cheney ML, LeJeune FE Jr, et al. Isolated uvulitis secondary to marijuana use. Laryngoscope 1988;98:1309-1312.
3. J. Huang . Isolated uvular angioedema in a teenage boy . The Internet Journal of Emergency Medicine 2007 Volume 3 Number 2
4. Miller RJ, Gerhardt MA. Uvular edema secondary to snoring under deep sedation. Anesth Prog 2006;53:13-16.
5. Schwartz R. Uvular edema and erythema (Letter). Pediatr Infect Dis J 1984;3:187.
6. McNamara R, Koobatian T. Simultaneous uvulitis and epiglottitis in adults. Am J Emerg Med 1997;15:161-163.

Online Resources:

1. http://www.anesthesiologieconferences.ca/crus/anestheng_1112_04.pdf
2. http://www.ispub.com/journal/the_internet_journal_of_emergency_medicine/volume_3_number_2_14/article/isolated_uvular_angioedema_in_a_teenage_boy-1.html

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