PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 22 noS. 1 & 2 January –June; July – december 2007 CASE REPORTS 22 PhiliPPine Journal of otolaryngology-head and neck Surgery ABSTRACT Objective: To describe a case of chronic cough due to pedicled uvular mucosal flap Design: Case report. Setting: A tertiary military hospital Patient: One (1) Result: A mucosal flap was seen arising from the uvula on oropharyngeal examination with a tongue depressor. Nasopharyngoscopy documented its extension to the tongue base and hypopharynx. It was excised under local anesthesia with amelioration of complaints and cessation of cough. Conclusion: The etiology of chronic cough not attributable to chronic rhinosinusitis, asthma, gastroesophageal reflux, tuberculosis, dysfunctional swallowing or cigarette smoking should be investigated further. A simple oropharyngeal examination (as in this case) may reveal the cause and a simple solution may be obtained, avoiding unnecessary investigations and treatment. Key words: Mucosal flap, uvula, chronic cough, pedicle. Chronic cough is defined as cough for more than four weeks. With careful history-taking and appropriate investigations, a single cause can be found in up to 82% of cases1. The majority of these can be successfully treated. The elongated uvula is previously reported in children as a cause of chronic cough2-6 even though it is an unusual reason for chronic cough in adults. To our knowledge this is the first reported case of chronic cough due to a uvular mucosal flap. Pediculated Mucosal Flap of the Uvula: an Unusual Cause of Chronic Cough in an Adult Murat Enoz, MD Department of Otolaryngology Head & Neck Surgery Maresal Cakmak Military Hospital, Erzurum, Turkey. Correspondence: Murat Enoz, MD Department of Otolaryngology Head & Neck Surgery Maresal Cakmak Military Hospital, 25700 Yenisehir, Erzurum, Turkey Phone: +905554293937 Fax: +902123439040 Email: muratenoz@gmail.com Reprints will not be available from the author. No funding support was received for this study. The author signed a disclosure that he has no proprietary or financial interest with any organization that may have a direct interest in the subject matter of this manuscript, or in any product used or cited in this report. Philipp J Otolaryngol Head Neck Surg 2007; 22 (1,2): 22-23 c Philippine Society of Otolaryngology – Head and Neck Surgery, Inc. Figure I: All oropharyngeal structures seem normal without tongue depression (A). Thin, flaccid mucosal flap of the uvula (black arrow) with its pedicle is shown after tongue depression. The pedicle extended to the tongue base and hypopharyngeal structures (B). PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 22 noS. 1 & 2 January –June; July – december 2007 CASE REPORTS PhiliPPine Journal of otolaryngology-head and neck Surgery 23 CASE REPORT A 26-year-old male was referred to our clinic for evaluation of non productive chronic cough more than three years. The patient was neither a smoker nor drinker and had no pertinent medical history. A cursory oropharyngeal examination (without using a tongue depressor) suggested that all oropharyngeal structures were normal (figure I- A). However, depressing the tongue revealed a thin, flaccid mucosal flap extending from the uvula toward the tongue base (figure I-B). Fiberoptic nasopahryngoscopy confirmed attachment of the pedicle to the tongue base and lateral pharyngeal walls. Endoscopic laryngoscopy and the rest of the ORL HNS exam were normal. The mucosal flap was excised under the local anesthesia and his complaints were ameliorated. The patient was followed up for six months during which time, his cough did not recur. DISCUSSION An elongated uvula can flop down and touch various structures including the posterior pharyngeal wall, epiglottis, and vocal cords. Irritation of these structures can lead to chronic cough, which can be relieved by uvulectomy or uvuloplasty4, 5. In our case, not just a long uvula, but a pedicled uvular flap was irritating various structures in the upper airway, leading to chronic cough. The treatment of chronic cough should always be preceded by a systematic effort to exclude serious underlying illness and establish the cause of the cough. The etiology of chronic cough not attributable to chronic rhinosinusitis, asthma, gastroesophageal reflux, tuberculosis, dysfunctional swallowing or cigarette smoking should be investigated further. A simple oropharyngeal examination (as in this case) may reveal the cause and a simple solution may be obtained, avoiding unnecessary investigations and treatment. REFERENCES: 1. Irwin RS, Boulet LP, Cloutier MM, Fuller R, Gold PM, Hoffstein V, et al. Managing cough as a defense mechanism and as a symptom. A consensus panel report of the American College of Chest Physicians. Chest. 1998 Aug;114(2 Suppl Managing):133S-181S. 2. Pai V, Thomas H, Stewart C. Long uvula: an unusual cause of chronic cough. Postgrad Med J. 2004 Feb;80(940):116. 3. Najada A, Weinberger M. Unusual cause of chronic cough in a four-year-old cured by uvulectomy. Pediatr Pulmonol. 2002 Aug;34(2):144-6. 4. Shott SR, Cunningham MJ. Apnea and the elongated uvula. Int J Pediatr Otorhinolaryngol. 1992 Sep;24(2):183-9. 5. Miller FR, Tucker HM. An elongated uvula producing chronic cough. Otolaryngol Head Neck Surg 1993;109:954–5. 6. Landau LI. Acute and chronic cough Paediatr Respir Rev. 2006;7 Suppl 1:S64-7.