Severe Anemia following Uvulectomy in Kenya

Military Medicine, Sep 2004 by Lowe, Karla R

Uvulectomy is a common practice in eastern Africa for treatment of a variety of throat conditions. Traditional healers perform the procedure. I present a case report to illustrate a complication of uvulectomy. This is a report of a child who presented with severe anemia secondary to uvulectomy performed for treatment of chronic cough. This case report is intended to illustrate a procedure not commonly performed by western otolaryngologists and to describe the management of a severe complication. Western physicians are increasingly being tasked in medical situations in which they encounter traditional medical practices outside of their scope of training. The intent of this report is to familiarize western physicians with one such procedure and its potential complications.

Introduction

Uvulectomy is a common practice in eastern Africa for treatment of a variety of throat conditions. Traditional healers perform the procedure. I present a case report to illustrate a complication of uvulectomy.

Case Report

On February 10, 2003, a previously well, exclusively breastfed, 6-month-old female infant presented to the Malindi District Hospital (Malindi, Kenya) with a 3-day history of emesis, dark stools, poor feeding, and lethargy. The prenatal, perinatal, and previous medical histories were uncomplicated. Immunizations were current. There was no family history of anemia or bleeding disorders.

In the initial assessment, the infant was listless and pale. Vital signs were remarkable for a heart rate of 175 beats per minute. The physical examination revealed a soft flat anterior fontanelle, extremely pale conjunctiva and oropharynx, tachycardia, and symmetrical brisk pulses. No evidence of trauma, bruising, or bleeding was apparent in the skin examination. Examination of the oropharynx was remarkable for the absence of the uvula and for oozing blood. The parents had sought removal of the uvula by a traditional healer after 6 weeks of chronic cough, 6 days before presentation to the hospital.

Laboratory assessment revealed a hemoglobin level of 2.6 g/dL. A blood smear was notable for the absence of malaria parasites. No additional differential analysis was performed. The child was admitted to the pédiatrie ward and received whole blood (20 mL/kg) for treatment of symptomatic anemia. Additional treatments included standard medications for all pédiatrie admissions at the Malindi District Hospital, i.e., vitamin A, erythromycin, metronidazole, and mebendazole. The infant recovered completely after the transfusion, with resolution of the pallor and tachycardia.

Epidemiological Features

Uvulectomy is an uncommon procedure among western otolaryngologists. In fact, in the mid-1800s it was described as one of the rarest operations in otolaryngology. Uvulectomy is a far more common practice in eastern Africa.

Indications for the procedure are based on the premise that the uvula is responsible for medical problems within the throat. It is performed to prevent or treat organic conditions and is not related to ritual surgery, gender, or religion. Various indications for uvulectomy include cough, congestion, pharyngitis, and poor oral intake.1

Operative Techniques

Traditional healers perform the procedure in the morning, because blood is thought to have better hemostasis in the cold. A curved, sickle-shaped instrument fashioned from a metal rod is used. The patient is forcibly restrained. An assistant holds the head in position, and the instrument is inserted in a motion that both scoops and slices the uvula. Gargles and herbal extracts may be used to maintain hemostasis.2

Reported complications include postoperative hemorrhage, infection, cellulitis, peritonsillar and pharyngeal abscesses, upper airway obstruction, and pharyngolaryngocele with pneumothorax.2"4 Limited laboratory capabilities for blood screening make both infectious and hemolytic complications significant risks with blood transfusion.

Discussion

Local cultural experience suggested that this was a benign intervention. In fact, both parents and all siblings had previously undergone uvulectomies without incident. The relationship between the procedure and the subsequent anemia was therefore difficult for the family to understand.

This case is reported to illustrate a temporally remote, perhaps subtle complication of uvulectomy. Physicians currently practice in an expanding world. Increasing global mobility and emigration make previously localized practices universally relevant. As physicians in western practice increasingly provide care to families within and from eastern African nations, they may encounter uvulectomy; therefore, they should be familiar with its complications and their management.

References

1. Manni JJ: Uvulectomy, a traditional surgical procedure in Tanzania. Ann Trop Med Parasitai 1984; 78: 49-53.

2. Ijaduola GTA: Uvulectomy in Nigeria. J Laryngol Otol 1981; 95: 1127-33.

3. Adekeye EO, Kwamin F, Ord RA: Serious complications associated with uvulectomy performed by a "native doctor." Trop Doct 1984; 14: 160-1.