Introduction

Traditional African practitioners continue to perform uvulectomies at the request of their patients despite severe complications noted by physicians ₁ . These severe complications may require hospitalization ₂ Traditional uvulectomy is an African surgical practice that has been well documented in Kenya, Sierra Leone, Tanzania, Ethopia, South Africa and Nigeria ₂,₃,₄,₅,₆,₇,₈ . It has also been reported in Israel, Maghreb ₉ and Saudi Arabia ₁₀ . It is an unnecessary and potentially dangerous mutilation. The case presented is noteworthy for the life threatening complication of this traditional uvulectomy. To our knowledge this represents a rare case report of such complication resulting from uvulectomy. The need for continuous health education at the grassroots to prevent such practices is advocated

Case Report

An 82 year old widow presented on 27/12/2007 to the accident and emergency unit of Imo State University Teaching Hospital, Orlu, Nigeria with one week history of insidious onset of painful facial swelling, severe headache and bilateral chemosis, ptosis, and ophthalmoplegia. Two weeks prior to onset of her symptoms the patient complained of sore throat for which she consulted a traditional medical practitioner who carried out uvulectomy on her. Initially her throat pain was localized to the right side of the throat. Following the uvulectomy her condition deteriorated with swelling of the right side of her face, trismus, headache, high grade intermittent fever and anorexia. They sought treatment from the patent medicine dealer which was not helpful. With serious deterioration of her condition, her relations took her to a private medical practitioner who placed her on antibiotics and referred her to the Teaching Hospital.

On examination on arrival at the Accident and Emergency department she was toxic, ill-looking, dehydrated and semi-comatose. There were generalized tender and fluctuant facial swellings with severe chemosis, proptosis, ophthalmoplegia and ptosis. She could not open her eyes. Her pulse was 84/min; BP 110/70mmHg.. Foul smelling pus drooled from her mouth. Swabs were taken from the oral cavity and the face for culture and sensitivity; full blood count and skull Xrays; HIV screenings were requested. Diagnosis of Cavernous Sinus Thrombosis and Cellulitis complicating Traditional Uvulectomy was made. She was admitted and consultation made to the Ophthalmologist who reviewed her. The culture yielded heavy growth of staphylococcus aureus sensitive to ceftriazone, ofloxacin and ciprofloxacin. The PCV was 32%; WBC 9.7x 10⁷ litre and HIV screening was negative. Skull X-ray showed soft tissue oedema. She was placed on ceftriazone, metronidazole; and intravenous fluids with daily oral toilet and dressing of the sloughed skin on the face. She made remarkable improvement of her symptoms with medication. She fully recovered with treatment and was discharged on the 20 ^th day after admission.

Discussion

Uvulectomy in Africa is performed as a ritual custom on both boys and girls during the first or second years of life ₉. In some parts of Africa among the Hausa ethnic group, it is systematically performed on the seventh day after birth, during naming ceremony to prevent death due to a “swelling of the uvula” ₂,₁₁. In other sub-groups uvulectomy is solely done as a curative practice both for children and adults for complaints like sore throat, vomiting, diarrhea, anorexia, rejection of breast by a child, growth retardation and fever. Occasionally it is done to prevent throat infections and other disorders associated with the throat because it is believed that elongated uvula is the root cause of all throat problems ₆,₈. Uvulectomy is an unnecessary and potentially dangerous mutilation as it results in various complications including haemorrhage, septicemia, cellulitis of the neck, peritonsillar abscess, pneumothorax, parapharyngeal abscess and pharyngo-laryngocele ₇ .

In the reported case the uvulectomy done by the traditional practitioner was complicated by cellulitis of the face, and cavernous sinus thrombosis. CST is a rare condition that may lead to significant morbidity and mortality ₁₂ . Infections arising at locations such as the face, nose, sinuses, tonsils, soft palate, teeth and ears, ₁₃ can lead to CST. Most of these patients will develop fever, ptosis, proptosis, chemosis and external ophthalmoplegia. In this age of antibiotics mortality of CST has drastically reduced. The commonest organism in CST infection is staphylococcus aureus. Such antibiotics like metronidazole, ceftriazone and cetrixine are used to contain these organisms. In the reported case the patient made full recovery with treatment and was discharged. Most Africans of the age grade of the reported case would still seek medical care from the traditional healer despite the presence of western orthodox medicine in their area. She still recoursed to seek the assistance patent medicine dealers. Orthodox medicine was her last resort only when her condition had become complicated and life threatening. Health education at the grass root level is still lacking in most developing countries like Nigeria. It is only through well articulated health education programs that patients in remote areas can be made to seek appropriate care in order to avoid life threatening complications like the case presented.