Why do we have a uvula?: literature review and a new theory

Uvula infections and traditional uvulectomy: Beliefs and practices in Luwero district, central Uganda

Uvulitis is the inflammation and swelling of the uvula, usually associated with infection of nearby structures. Uvulitis can be treated symptomatically, using medication or in some cases with uvulectomy, the uvula surgical removal or shortening. Traditional uvulectomy by traditional practitioners has been practiced in Africa for ages, associated with adverse outcomes. Although there is no empirical evidence for the association between adverse outcomes and traditional uvulectomy in Uganda, anecdotal findings showed incidents of uvula infections following uvulectomy in central Uganda. While these findings also indicate that traditional uvulectomy is common, the community understanding of uvulitis, the beliefs and practices are not well understood. This qualitative study sought to understand beliefs and practices using interviews with community health workers, traditional uvulectomy clients, and traditional surgeons, and focus group discussions with community members. Transcribed data were analysed in Atlas.ti 9 using thematic analysis steps. The findings show that uvula infection, locally known as "Akamiro" and the associated traditional uvulectomy are common in Luwero and beyond. "Akamiro" was described as larger than the normal, the size of a chicken heart or a big pimple, visible when a child cries, with unknown causes. Symptoms included persistent cough, diarrhoea, vomiting, loss of appetite, inability to swallow and ultimately weight loss, swollen stomach, saliva overflow, fever, breathing and speech difficulty. Diagnosis was confirmed after seeking care from health workers or in consultation with significant others and finally the traditional surgeon; in a hierarchical pattern. Uvulectomy was conducted by traditional surgeons, with surgery lasting a few minutes, in the morning or after sun-set. Tools used were razor blades, reeds, strings, wires, sickle knives and spoons. Payment was flexible; cash or in-kind. Surgeons had immense community trust, including community health workers. Interventions to support persons with uvula infections need to address the health system weaknesses, and health education.

Extracting signature responses from respiratory flows: Low-dimensional analyses on Direct Numerical Simulation-predicted wakes of a flapping uvula

Uvula-induced snoring and associated obstructive sleep apnea is a complex phenomenon characterized by vibrating structures and highly transient vortex dynamics. This study aimed to extract signature features of uvula wake flows of different pathological origins and develop a linear reduced-order surrogate model for flow control. Six airway models were developed with two uvula kinematics and three pharynx constriction levels. A direct numerical simulation (DNS) flow solver based on the immersed boundary method was utilized to resolve the wake flows induced by the flapping uvula. Key spatial and temporal responses of the flow to uvula kinematics and pharynx constriction were investigated using continuous wavelet transform (CWT), proper orthogonal decomposition (POD), and dynamic mode decomposition (DMD). Results showed highly complex patterns in flow topologies. CWT analysis revealed multiscale correlations in both time and space between the flapping uvular and wake flows. POD analysis successfully separated the flows among the six models by projecting the datasets in the vector space spanned by the first three eigenmodes. Perceivable differences were also captured in the time evolution of the DMD modes among the six models. A linear reduced-order surrogate model was constructed from the predominant eigenmodes obtained from the DMD analysis and predicted vortex patterns from this surrogate model agreed well with the corresponding DNS simulations. The computational and analytical platform presented in this study could bring a variety of applications in breathing-related disorders and beyond. The computational efficiency of surrogate modeling makes it well suited for flow control, forecasting, and uncertainty analyses.

Prevalence of bifid uvula in primary school children

BACKGROUND

A bifid uvula is an anatomic variation that can be predictive of sub-mucous cleft palate, which may cause velopharyngeal insufficiency (VPI). Bifid uvula prevalence in the literature ranges from 0.18% to 10.3%, depending on the population studied. The aim of this study is to determine the prevalence of bifid uvula in the Geneva's school children population.

METHODS

A cross-sectional study was conducted in Geneva's primary school children, from September 2014 to June 2015. An examination of the uvula was performed by dentists working for the Scholastic Dental Service, after a specific training in diagnosing bifid uvulas. The dentists recorded their findings on a standardized form.

RESULTS

The total number of school children in Geneva in the school year 2014-2015 was 30,375. 23,961 children had their uvula examined, representing 79% of the total population of school children. Among them, a hundred school children had a cleft uvula. One schoolgirl had no uvula. The prevalence of bifid uvula is 0.42%. Sex ratio (M/F) is 0.96.

DISCUSSION

This large study, the second in literature for number of patients examined, identified a prevalence of bifid uvula of 0.42%. This result is in agreement with previous studies.

The Significance of Uvula After Palatoplasty: A New Technique to Improve the Aesthetic Outcome

OBJECTIVE

This study aims to examine the importance of the uvula as a part of palatoplasty outcome and to assess the aesthetic results of the conventional versus a new technique for uvuloplasty.

DESIGN/PARTICIPANTS

The study included 2 groups of patients undergoing palatoplasty. Group I consisted of 20 cleft palate patients repaired with the conventional uvula repair, combining the 2 hemi-uvulae. Group II consisted of 20 patients repaired with our new technique, sacrificing one hemi-uvula and centralizing the remaining one. The aesthetic outcome was assessed in both groups. A questionnaire was distributed to the families of both groups to assess their concern about the uvula after palate repair.

SETTING

Cleft unit at a tertiary care center.

RESULTS

Sixty-five percent of parents considered the uvula as important functionally and aesthetically after palate repair whereas 35% either did not care or were not sure about its importance. Results of the aesthetic outcome of the 2 techniques for uvula reconstruction showed that uvula was absent in 4 cases in group I versus 1 in group II ( P > .05), small in 8 cases of group I versus 4 in group II ( P > .05), bifid in 5 cases of group I versus none in group II ( P < .05), became deviated in no case of group I versus 4 in group II ( P > .05), and was satisfactory in 3 cases of group I versus 11 in group II ( P < .05).

CONCLUSIONS

Among the respondents, the uvula was a significant concern to the parents of cleft patients and should be given more attention during repair. The described technique had better aesthetic outcome over the conventional one of combining the 2 hemi-uvulae.

Novel Surgical Approaches for the Treatment of Obstructive Sleep Apnea

Novel approaches to upper airway anatomic phenotyping, more reconstructive upper airway surgical techniques, and new implantable hypoglossal neurostimulation technology have very favorable potential to improve symptoms and quality-of-life measures, to reduce obstructive sleep apnea (OSA) disease severity and associated cardiovascular risk, and to serve as an adjunct to continuous positive airway pressure, oral appliances, and other forms of OSA medical therapy. Successful surgical therapy depends critically on accurate diagnosis, skillful knowledge and examination of the upper airway anatomy, proper procedure selection, and proficient technical application.

Double uvula in a fifty-six-year-old woman

Introduction:

Deformities of the uvula are considered as the dark area of otorhinolaryngology practice. This little and plain part of the human organism has various functions and its abnormalities might cause serious disabilities.

Case Presentation:

In our case report, we present a unique deformity of the uvula in a 56-year-old woman.

Discussion:

The aim of this report was to present a very rare condition, unique case “polyuvula”, and to review the literature regarding other uvula abnormalities.

Bilateral glossopharyngeal nerve palsy following tonsillectomy: a very rare and difficult complication of a common procedure

Objectives:

Tonsillectomy is one of the most commonly performed otolaryngological procedures. Bilateral palsy of the glossopharyngeal nerve is an exceedingly rare complication that can result in significant morbidity. This case report aimed to raise awareness of this complication and outline management strategies.

Case report:

A 31-year-old woman who underwent routine tonsillectomy presented with progressive numbness of the palate, dysgeusia, xerostomia, paraesthesia of the tongue and the feeling of something in her throat within 2 weeks of surgery. She reported the post-operative onset of snoring. Examination revealed a symmetrically low, ‘dropped’ soft palate. Over time, her symptoms have lessened, but dysgeusia and snoring remain.

Conclusion:

The position of the glossopharyngeal nerve in the tonsillar bed makes it prone to injury during tonsillectomy, especially if ‘hot’ methods are used. Bilateral injury can result in significant morbidity that can be difficult to treat. Patients should be warned about this risk and care should be taken to minimise it.

OSAS surgery and postoperative discomfort: phase I surgery versus phase II surgery

Introduction. This study aims to investigate the reasons that discourage the patients affected by OSAS to undergo orthognathic surgery and compares the postoperative discomfort of phase I (soft tissue surgery) and phase II (orthognathic surgery) procedures for treatment of OSAS. Material and Methods. A pool of 46 patients affected by OSAS was divided into two groups: “surgery patients” who accepted surgical treatments of their condition and “no surgery patients” who refused surgical procedures. The “surgery patients” group was further subdivided into two arms: patients who accepted phase I procedures (IP) and those who accepted phase II (IIP). To better understand the motivations behind the refusal of II phase procedures, we asked the patients belonging to both the IP group and “no surgery” group to indicate the main reason that influenced their decision to avoid II phase procedures. We also monitored and compared five parameters of postoperative discomfort: pain, painkiller assumption, length of hospitalization, foreign body sensation, and diet assumption following IP and IIP procedures. Results. The main reason to avoid IIP procedures was the concern of a more severe postoperative discomfort. Comparison of the postoperative discomfort following IP versus IIP procedures showed that the former scored worse in 4 out of 5 parameters analyzed. Conclusion. IIP procedures produce less postoperative discomfort. IIP procedures, namely, orthognathic surgery, should be the first choice intervention in patients affected by OSAS and dentoskeletal malformation.

Limited palatal muscle resection with tonsillectomy: a novel palatopharyngoplasty technique for obstructive sleep apnea

OBJECTIVE

The ideal palatal surgery for obstructive sleep apnea (OSA) and snoring must maintain the airway patency and correct anatomic abnormalities without complications. The purpose of this study was to investigate the efficacy of limited palatal muscle resection (LPMR) to improve OSA severity.

SUBJECTS AND METHODS

Twenty-three patients with OSA underwent LPMR. The LPMR was initiated with a bilateral tonsillectomy in patients with tonsil size 2 and 3. The LPMR consisted of partial resection of palatal muscles (levator veli palatini, palatoglossus, and musculus uvulae) with preservation of the uvula and a simple double layer suturing. The retropalatal space and the length of soft palate were evaluated by magnetic resonance imaging. Subjective outcomes using visual analog scales, Epworth Sleepiness Scale, and overnight polysomnography (PSG) data were assessed.

RESULTS

Six months after the operation, there was significant symptomatic improvement in snoring, morning headaches, tiredness, and daytime sleepiness. Postoperative magnetic resonance images showed upward and forward movement of uvula and soft palate after LPMR. The length of the soft palate was significantly shortened and the retropalatal space was significantly increased. Postoperative PSG revealed significant improvement in apnea-hypopnea index (AHI) and the total sleep time spent with oxygen saturation below 90%, and reduction in AHI following PMR was found in all patients. Furthermore, no patient experienced velopharyngeal insufficiency, voice changes, and pharyngeal dryness at 6 months follow-up.

CONCLUSIONS

The LPMR obtained significant improvement in subjective and objective outcomes in OSA, with preserved pharyngeal function. PMR is an effective and safe technique to treat oropharyngeal obstruction in OSA surgery.

TGFβ regulates epithelial-mesenchymal interactions through WNT signaling activity to control muscle development in the soft palate

Clefting of the soft palate occurs as a congenital defect in humans and adversely affects the physiological function of the palate. However, the molecular and cellular mechanism of clefting of the soft palate remains unclear because few animal models exhibit an isolated cleft in the soft palate. Using three-dimensional microCT images and histological reconstruction, we found that loss of TGFβ signaling in the palatal epithelium led to soft palate muscle defects in Tgfbr2(fl/fl);K14-Cre mice. Specifically, muscle mass was decreased in the soft palates of Tgfbr2 mutant mice, following defects in cell proliferation and differentiation. Gene expression of Dickkopf (Dkk1 and Dkk4), negative regulators of WNT-β-catenin signaling, is upregulated in the soft palate of Tgfbr2(fl/fl);K14-Cre mice, and WNT-β-catenin signaling is disrupted in the palatal mesenchyme. Importantly, blocking the function of DKK1 and DKK4 rescued the cell proliferation and differentiation defects in the soft palate of Tgfbr2(fl/fl);K14-Cre mice. Thus, our findings indicate that loss of TGFβ signaling in epithelial cells compromises activation of WNT signaling and proper muscle development in the soft palate through tissue-tissue interactions, resulting in a cleft soft palate. This information has important implications for prevention and non-surgical correction of cleft soft palate.

The Traditionally Amputated Uvula amongst Nigerians: Still an Ongoing Practice

Traditional healers in Nigeria continue to perform uvulectomy for all throat problems despite the severe complications they present to physicians. It is a hospital-based prospective study done at the outpatient unit of the Department of Otolaryngology, Jos University Teaching Hospital, Jos, Nigeria to determine the prevalence of traditional uvulectomy, highlighting the dangers it portends with suggested ways of providing improved health outcomes for our people. We saw 517 new cases of which 165 (32%) patients aged 2 years to 53 years had their uvulae amputated consisting of 108 (65.5%) males and 57 (34.5%) females giving a male to female ratio of 2 : 1. One hundred and forty two (86.1%) patients had uvulectomy at childhood and 23 (13.9%) in adulthood. The commonest indication was throat pain (n = 36, 21.8%). The commonest complication was hemorrhage (n = 29, 17.6%). Forty six (27.9%) patients required hospital admission.

'A good shepherd, but with obstructive sleep apnoea syndrome': traditional uvulectomy case series and literature review

BACKGROUND

In the West, removal of the uvula is predominantly undertaken as part of palatal surgery, in cases of obstructive sleep apnoea. In the developing world, such as the Middle East and Africa, uvulectomy is a more common practice. The uvula is removed for curative or preventive purposes, or as part of ritual practice. Due to immigration from developing to developed world countries, and to Western doctors working abroad, such doctors are increasingly being confronted with unfamiliar traditional healing practices, within a medical context.

METHODS

The Medline and Embase online databases were systematically searched for literature on traditional uvulectomy. We present a review of this literature. We also present the first report, to our best knowledge, of obstructive sleep apnoea as a late complication of traditional uvulectomy.

DISCUSSION

Traditional uvulectomy may be complicated by post-operative haemorrhage and local infections, among many other problems. We report cases of obstructive sleep apnoea and snoring caused by palatal stenosis resulting from traditional uvulectomy during childhood.

The effect of uvula-preserving palatopharyngoplasty in obstructive sleep apnea on globus sense and positional dependency

Objectives

This study investigated the outcomes of uvula-preserving palatopharyngoplasty (UPPPP) in patients with obstructive sleep apnea syndrome (OSAS).

Methods

Twenty men with obstructive sleep apnea syndrome received the UPPPP operation at our institution. We measured symptom changes after UPPPP using a visual analog scale (VAS), and all patients were examined with polysomnography pre- and post-operatively. 'Surgical success' was defined as reduction in apnea-hypopnea index (AHI) to below 20 events per hour and more than 50% post-operative reduction.

Results

Snoring decreased significantly (6.7±2.3 to 3.7±2.9 on VAS, P=0.002) but the postoperative globus sense did not differ from that preoperatively (2.0±2.4 to 2.1±2.7 on VAS, P=0.79). Apnea and apnea-hypopnea indices were significantly reduced after UPPPP (34.7±20 to 24.2±17.2 events/hour, P=0.029). The surgical success rate was 40% regardless of Friedman stage. There was significant reduction in the AHI on supine sleep in both surgically successful and unsuccessful patient groups.

Conclusion

UPPPP may minimize postoperative globus sense and other complications, with a success rate comparable to that of previously reported surgical methods in OSAS patients. In addition, it may reduce the apnea-hypopnea index in the supine sleep position.

Modified uvulopalatopharyngoplasty for the treatment of obstructive sleep apnea-hypopnea syndrome: Resection of the musculus uvulae

Objective: To assess the outcome of a modified uvulopalatopharynbgoplasty (UPPP) technique with preservation of the uvula mucosa and partial resection of the musculus uvula.

Study Design and Methods: A prospective randomized controlled trial. Sixteen male patients underwent a classic UPPP, and another 16 male patients underwent a modified UPPP. The parameters evaluated were the subjective symptom score, the Pittsburgh Sleep Quality Index (PSQI), the Epworth Sleepiness Scale (ESS), the Stanford Sleepiness Scale (SSS), and polysomnography results.

Results: Postoperative snoring, apnea, morning headache, daytime sleepiness, pharyngeal foreign body sensation, and global discomfort were not significantly different between the two groups. Among seven subjective measures of sleep quality from the PSQI, the subjective sleep quality was significantly improved in both groups. Postoperatively, the SSS was not significantly changed in both groups; however, the ESS was significantly improved in both groups. The polysomnographic findings showed a statistically significantly improvement in the apnea index and the apnea-hypopnea index.

Conclusion: Although the modified group did not have more profound improvement in sleep quality and decreased postoperative pharyngeal discomfort, modified UPPP was an effective surgical method for the treatment of obstructive sleep apnea-hypopnea syndrome.

Condutas terapêuticas para tratamento da Síndrome da Apnéia e Hipopnéia Obstrutiva do Sono (SAHOS) e da Síndrome da Resistência das Vias Aéreas Superiores (SRVAS) com enfoque no Aparelho Anti-Ronco (AAR-ITO)

Os autores apresentam uma revisão da literatura referente às alternativas de tratamento cirúrgicas e não-cirúrgicas para a Síndrome da Apnéia e Hipopnéia Obstrutiva do Sono (SAHOS) e para a Síndrome da Resistência das Vias Aéreas superiores (SRVAS) com enfoque no princípio de ação e evolução dos aparelhos de avanço mandibular e, em particular, no mecanismo dinâmico de ação do Aparelho Anti-Ronco® (AAR-ITO).