Traditional uvulectomy is an excision of the uvula, usually performed by nonphysician healers. The procedure has been touted as a remedy for, or prevention of, infections associated with throat and chest and has also been completed as part of ritual practice [
In sub-Saharan Africa, traditional uvulectomy is largely driven by indigenous beliefs and cultural practices [
In Tanzania, the practice of uvulectomy is a relatively common phenomenon [
In this retrospective chart review study, we reviewed the records of all pediatric patients seen in the emergency department of a large national hospital during the year 2012 to describe the clinical presentations and outcomes of children presenting with complications from traditional uvulectomy.
The investigation was conducted at the Muhimbili National Hospital (MNH) Emergency Department (ED) in Dar es Salaam, Tanzania. Established in 2010, the MNH ED is the first full-capacity ED in Tanzania and is the clinical training site for the country’s first emergency medicine residency program.
The department is staffed by interns (fresh graduates from medical school), registrars (registered medical practitioners each with 1–3 years of clinical experience following internship), and emergency medicine residents (all had already worked as registrars before joining the 3-year residency program). These doctors work under the clinical supervision of the locally trained emergency physician faculty with support and consultation from board-certified emergency physicians from the USA, Canada, and South Africa.
MNH is the largest tertiary care center in Tanzania and the ED serves a high acuity patient population from within Dar es Salaam as well as referral patients from throughout the country. Of the 36000 adult and pediatric patients seen each year, only 20% are discharged home from the ED. The top five categories of complaints seen in the department are trauma, infectious, mental health, neoplastic, and pregnancy-related issues [
This was a prespecified subgroup analysis of a retrospective chart review of all children (less than 18 years old) seen in the MNH ED from 1 January 2012 to 31 December 2012. Trained physician abstractors reviewed the ED and inpatient records for all children presenting to the MNH ED during the study period. Data were recorded on a structured case report form, including basic demographics, reported initial complaints, final EMD diagnoses, and final hospital discharge diagnosis.
For this investigation, we examined all presentations associated with complications of traditional uvulectomy, including the clinical findings, treatment rendered, and patient outcomes.
Data were imported into an Excel spreadsheet (Microsoft Corporation, Redmond, WA, USA), cleaned, and analyzed with StatsDirect (v 3.0.133, Cheshire, UK). We report descriptive statistics, including mean and standard deviations, medians and interquartile ranges, and counts and percentages as appropriate for the data type and distribution. Confidence intervals were calculated by the Clopper-Pearson (exact) method. Categorical values were compared between groups using the Chi Square test.
The Senate research and publication committee of the Muhimbili University of Health and Allied Sciences reviewed the study protocol and granted ethical approval, including waiver of informed consent.
According to the patient logs, a total of 5774 children presented to the MNH ED from 1 January 2012 to 31 December 2012. Of these, 5540 (96%) patient files were available for review and data abstraction. A total of 56 patients (1.0%, 95% CI: 0.7–1.3%) met our inclusion criteria of presentation due to complaint associated with recent traditional uvulectomy. Of those included, 30 (53.6%) of the study populations were male, with median age of 1.3 years (interquartile range: 7 months to 2 years), and 55 (98%) were below 5 years of age (Table
Baseline characteristics of the patients.
Variable | All ( |
---|---|
Age | |
Overall: median |
1.3 years |
1–6 months | 7 (13) |
6 months–<1 year | 18 (32) |
1 year–5 years | 30 (54) |
>5 years | 1 (2) |
Gender | |
Male | 30 (54) |
Female | 26 (46) |
The main presenting symptoms were cough in 46 (82%), report of fever prior to presentation in 26 (46%), and hematemesis in 21 (38%). The main physical examination findings documents in the ED charts were fever in 30 (54%), tachypnea in 17 (30%), tachycardia in 14 (25%), and hypoxia in 6 (11%) (Table
Clinical findings during EMD presentation.
Presenting symptoms |
|
---|---|
Cough | 46 (82) |
Report of fever prior to presentation | 26 (46) |
Vomiting blood | 21 (38) |
Difficulty in breathing | 12 (21) |
Abdominal distension | 6 (11) |
Chest pain | 5 (9) |
Others |
10 (18) |
|
|
Physical findings and vital signs |
|
|
|
Temperature > 37.5°C | 30 (54) |
Tachypnea | 17 (30) |
Tachycardia | 14 (25) |
Oxygen saturation < 90% | 6 (11) |
Bradycardia (<80 beats/min) | 5 (9) |
The most common final ED diagnoses were pneumonia in 23 (41%), severe anemia, classified according to the World Health Organization definition as a hemoglobin measurement of less than 7 g/dL [
Final ED diagnoses.
Diagnoses |
|
---|---|
Pneumonia | 23 (41) |
Upper GI bleeding | 20 (36) |
Severe anemia | 20 (36) |
Malaria | 10 (18) |
HIV | 8 (14) |
Tuberculosis | 3 (5) |
Bronchitis | 1 (2) |
The most common final hospital discharge diagnoses were pneumonia in 23 patients (44%), upper GI bleeding in 24 patients (46%), Malaria in 22 patients (42%), HIV in 11 patients (21%), and severe anemia and malnutrition in 10 patients (19%). As was seen with the ED diagnoses, bronchitis was the least common hospital discharge diagnosis (Table
Final hospital diagnoses.
Diagnoses |
|
---|---|
Upper GI bleeding | 24 (46%) |
Pneumonia | 23 (44%) |
Malaria | 22 (42%) |
HIV | 11 (21%) |
Severe anemia | 10 (19%) |
Malnutrition | 10 (19%) |
Septicemia | 3 (6%) |
Tuberculosis | 3 (6%) |
Bronchitis | 1 (2%) |
Treatment included intravenous antibiotics for 35 patients (63%, 95% CI: 49–75%), blood transfusions for 11 (20%, 95% CI: 10–32%), and surgical interventions for 3 (5%, 95% CI: 1–15%); these surgical interventions included suture ligation for hemostasis, packing, and electrical cauterization to achieve hemostasis. Four patients (7%, 95% CI: 2–17%) died in the ED and the rest were admitted to the hospital: 42 (75%) to the general pediatric ward, 7 (13%) to the pediatric intensive care unit, and 3 (5%) to the pediatric surgical service. Eight of the admitted patients died in the hospital for a total mortality of 12 (21%, 95% CI: 12–34%) among the study cohort (Table
Disposition.
Disposition | All ( |
---|---|
General pediatric ward | 42 (75) |
Intensive care unit | 7 (13) |
Pediatric surgery | 3 (5) |
Died at EMD | 4 (7) |
|
|
Clinical outcome | All ( |
|
|
Survived to discharge | 44 (79; 66–88) |
Died (both in the ward and EMD) | 12 (21; 12–34) |
Our investigation found that 1% of children presenting to the MNH ED in the year 2012 had complaints related to a recent traditional uvulectomy and nearly all were under the age of 5 years. These findings are similar to those seen in other African countries [
The predominant symptoms at ED presentation in our cohort were cough, difficulty in breathing, fever, and hematemesis. All the children had at least one abnormal physical finding or vital sign at the time of presentation to the emergency medicine department, with more than half of the patients presenting with fever. Other observed abnormalities included tachypnea, tachycardia, and hypoxia. We were not able to establish with certainty that the presenting symptoms of our cohort were due to complications of the procedure or from preexisting medical conditions that prompted the procedure. Regardless, the observed mortality was more than twice that of all other children presenting to the ED during the study period. Previous studies from throughout Africa have shown that cough, throat pain, dysphagia, and loss of appetite are among the most common indications for traditional uvulectomy as stated by the traditional healers [
The top final ED diagnoses were pneumonia, upper GI bleeding, and severe anemia. The most common hospital discharge diagnoses were similar but also included malaria. Prior work in similar settings has demonstrated that respiratory infections and malaria remain among the top causes of hospital admission [
None of the children in this group were discharged from the emergency department, 63% received intravenous antibiotics, 20% received a blood transfusion, and 5% required immediate surgical intervention for hemorrhage control. Prior studies have reported infections and bleeding as the major complications of uvulectomy, including one in which hemorrhage was present in over 50% of the patients, with the majority requiring surgical intervention to achieve hemostasis [
The overall mortality rate of our cohort was high (21%) with one-third of those children dying in the ED and the rest succumbing during their hospital admission. This observed morality among those presenting following a recent uvulectomy was more than double that of all other children presenting to the ED during the study period (21% versus 9%, resp.,
The limitations of this study include the retrospective design and the relative paucity of clinical data available from the patients’ charts. Due to the nature of the study, we were unable to reliably identify the symptoms that prompted the uvulectomy. Hence, we cannot reliably differentiate between the initial symptoms and the subsequent complications of the procedure. Likewise, we were unable to demonstrate the exact cause of death for the 12 patients who died and are unable to definitively prove whether the uvulectomy contributed to their demise.
In our cohort of 56 patients, representing nearly 1% of all children presenting to the MNH ED in 2012, traditional uvulectomy was associated with significant morbidity as evidenced by the need for antibiotic therapy, blood transfusions, and surgical intervention. The observed mortality rate of 21% was more than twice that of all other children presenting to the ED during the study period. These findings are alarming given that the procedure confers no clinical benefit. Emergency care providers should advocate for legal and public health interventions to eliminate this dangerous practice.
Emergency Department
Gastrointestinal
Human immunodeficiency virus
Muhimbili National Hospital
Muhimbili University of Health and Allied Sciences
United Kingdom
United States of America.
The authors declare that there is no conflict of interests regarding the publication of this paper.