Etiology

The main bacterial agents that cause uvulitis in children include Haemophilus influenzae type b and Streptococcus pyogenes. Uvulitis caused by H. influenzae may occur concurrently with epiglottitis or as an isolated infection. Uvulitis caused by S. pyogenes seems always to occur in concert with pharyngitis. Brook reported two cases of uvulitis caused by anaerobic bacteria ( Fusobacterium nucleatum and Prevotella intermedia ). No search for viral agents has been conducted. Several cases of uvulitis caused by Candida albicans have been described in immunocompetent toddlers. In adults, Streptococcus pneumoniae and H. influenzae have been reported to cause uvulitis. In many patients, an associated epiglottitis has been present.

Epidemiology

The epidemiology of uvulitis is the epidemiology of its two etiologic agents, S. pyogenes and H. influenzae type b. It occurs in school-aged children 5 to 15 years old (the so-called streptococcal age group) in association with pharyngitis. Similarly, it can be seen in the H. influenzae age group (3 months to 5 years) if a child has not received the now routine and universally recommended conjugate vaccine to prevent infections caused by H. influenzae type b. Cases of uvulitis in association with epiglottitis have been reported in the United States and in England. Infections caused by S. pyogenes and H. influenzae occur primarily in the winter and spring, but both types can occur throughout the year.

Pathogenesis

Uvulitis is an acute cellulitis characterized by dramatic swelling and erythema. Infection of the uvula probably arises from direct invasion by S. pyogenes or H. influenzae type b; both are recognized as normal nasopharyngeal flora. In the latter case, epiglottitis also may arise by direct extension, and the bacteremia may result secondarily from either the uvula or the epiglottis as a primary site of infection.

Uvulitis that is noninfectious may result from injury, chemical irritation, or allergic inflammation. An occurrence in a child who was ultimately diagnosed to have Kawasaki disease also has been reported.

Clinical Manifestations

In a review of five patients with streptococcal uvulitis, all had associated pharyngitis. The patients presented with low-grade fever and sore throat. Three of the five patients experienced a choking or gagging sensation in the pharynx that induced coughing and spitting; one of these patients also presented with drooling. Although pharyngitis was noted on physical examination, the swelling and erythema of the uvula were most dramatic ( Fig. 10.1 ). None of the patients had evidence of respiratory distress.

Swollen (two to three times normal size) and erythematous uvula in a patient without epiglottitis or pharyngitis.

In most children with uvulitis and epiglottitis, the presentation usually is typical for epiglottitis, with sudden onset of high fever, dysphagia, and increasing respiratory distress. Rapkin, however, reported a case of uvulitis and epiglottitis in a child in which the epiglottitis initially was unsuspected. The same observation has been made in some adults with uvulitis and epiglottitis. Lateral neck radiography (performed in one case to evaluate the possibility of a retropharyngeal abscess) belatedly alerted the clinicians to the correct diagnosis.

In patients with uvulitis and no epiglottitis, the presentation may be similar to that of epiglottitis, with acute onset of fever, odynophagia, and drooling, or, less specific, with fever and irritability or decreased appetite. The diagnosis in these cases is provided by physical examination of the oropharynx, which shows a swollen and erythematous uvula (see Fig. 10.1 ).