S4514 Caught Between the Scope and Hard Palate: A Case of Uvular Necrosis Post-ERCP

Introduction: Uvular trauma is a rare complication of upper endoscopy procedures, often resulting from endoscope-induced pressure on the uvula or vigorous oropharyngeal suctioning. Symptoms include sore throat, foreign body sensation, odynophagia, dysphagia, and fever. Early identification is crucial as uvular necrosis can lead to airway obstruction, bleeding, infection, and even perforation. Management is typically conservative, but close monitoring is necessary. Here, we present a rare case of uvular necrosis following an upper endoscopic procedure. Case Description/Methods: A 57-year-old man with hyperlipidemia and a pancreatic head mass presented with 6 weeks of worsening epigastric pain and jaundice. He underwent endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic ultrasound/fine needle aspiration for tissue diagnosis with biopsy and biliary decompression with stent placement. The procedure itself was technically successful without immediate adverse events. However, that night, the patient developed significant throat irritation, a persistent foreign body sensation, pain, and heaviness localized to the back of his throat, exacerbated by lying supine. Physical examination revealed an enlarged, black-discolored uvula with an adherent moderate-sized blood clot, surrounded by oropharyngeal erythema and swelling. His airway was patent (Mallampati class 4 noted), with no stridor, respiratory distress, or active bleeding. A computed tomography soft tissue neck ruled out retained foreign bodies or deep space collections. Otolaryngology diagnosed uvular necrosis secondary to endoscope trauma during the ERCP. The patient was managed conservatively with intravenous dexamethasone (for inflammation), analgesics, mouthwash, and diet modification, leading to gradual symptom resolution. Discussion: Uvular necrosis is a rare complication of upper endoscopy, typically caused by direct endoscope trauma compressing the uvula against the pharynx or excessive suctioning, leading to vascular compromise and ischemic necrosis. Key risk factors include male sex, large neck circumference, and difficult airways (e.g., Mallampati 4). Patients present with acute sore throat, odynophagia, dysphagia, and foreign body sensation. Diagnosis is clinical, identifying a swollen, black-discolored necrotic uvula. Management is conservative with steroids to reduce inflammation, analgesics control pain, and supportive care (soft diet, mouthwash) aids healing. Symptoms typically resolve within 4-7 days; surgery is rarely needed. Prevention focuses on gentle technique and airway assessment in high-risk patients.