[Cervical granulomatous lymphadenitis: report of 13 cases]

The most common manifestation of mycobacterial infection encountered in E.N.T. practice is cervical lymphadenitis. Mycobacterial cervical lymphadenitis, the so-called scrofula, remains a diagnostic challenge, because it mimics other resembling processes. We present 13 cases of cervical granulomatous lymphadenitis treated from 1967 until 1990.

[Tuberculous adenopathies of the mediastinum: surgical experience in adults]

Fifty eight patients were treated for mediastinal tuberculous adenopathies in the thoracic surgery department from 1986 to 1992. Surgery was diagnostic in 49: mediastinoscopy n = 42, left anterior mediastinotomy n = 3, thoracotomy n = 3 and video assisted surgery n = 1. Surgery was in view of cure in 9: bronchial fistula despite medical treatment n = 6, recurrence under medical treatment n = 3. Mediastinal tuberculous adenopathies rarely complicate in adults. Surgical treatment is quickly effective in prolonging and complicating cases under medical treatment and also probably diminishes the risk of bronchial and pulmonary sequellaes.

[Differential diagnosis of neck swelling due to suspected metastasis using positron emission tomography]

A noninvasive diagnostic method for the evaluation of a suspicious mass in the neck can be of great value for further diagnostic approach. The differing metabolic activity of malignant and benign tumors offers the possibility to determine the status of a lesion by the quantitative evaluation of the glucose uptake by positron emission tomography (PET). The diagnostic relevance of the metabolic activity has been shown earlier in more than 50 malignant tumors of the head and neck (Reisser et al., HNO 40 [1992] 225-231). The present study demonstrates the determination of tumor status in two benign and two malignant tumors of the neck by PET. Quantitative evaluation of the glucose uptake revealed significantly higher values in malignant than in benign lesions. Therefore the determination of the glucose metabolism prior to the indispensable histological diagnosis of the status of a lesion can provide valuable hints for the further diagnostic and therapeutic approach to the lesion.

[Manifestation of lung tuberculosis as soft tissue tumor (gravitation abscess in mediastinal lymphadenitis) of the thoracic wall in a 32-year-old woman]

In a 32-year-old female appeared after a period of weeks with pain in the back and left flank a tumor (8 x 6 cm in size) in the anterior axillary line (9.-11. rib). The patient was afebril and in good condition. X-rays and Contrast-CT findings showed round shaped infiltrations in both upper lobes of the lung, widening of the mediastinum (right paratracheal) and left pleural effusion. The mediastinal mass showed "rim enhancement" and "central low density areas", which is typical for liquefaction of caseous material in tuberculous lymphadenitis and gravitation abscess. The tumor was resected incompletely, because there was connection to the 8. intercostal space. In the cross-section the tumor appeared grey-white, histologically there was caseous material surrounded by epitheloid cells and Langhans giant cells, as to see in tuberculous gravitation abscess. Ziehl-Neelsen-staining of resected material and bronchial secret was negative, but of both specimen Mycobacterium tuberculosis was cultured. The patient got a therapy with INH, Ethambutol, Pyrazinamid and Rifampicin. Regression of the parenchymal fokus and the mediastinal lymphadenitis was observed.

Three cases of mycobacterial cervical lymphadenitis

Three cases of mycobacterial cervical lymphadenitis in children are presented. The diagnosis and treatment are described in brief. None of the patients were from the risk groups traditionally associated with tuberculosis. With an increasing number of tuberculosis cases reported in the UK, the need for awareness of this re-emerging condition to ENT surgeons and paediatricians is stressed.

[Tuberculosis in the otorhinolaryngologic area. A still current differential diagnosis]

Between 1986 and 1992 18 cases of tuberculosis of the cervical lymph nodes, the larynx, the middle ear, or the paranasal sinuses were diagnosed at the ENT clinic of the University of Erlangen-Nuremberg. A rare case of tuberculous infection of both the maxillary and ethmoidal sinuses and the pharyngeal tonsil is presented. All patients with involvement of the upper respiratory tract had concomitant productive pulmonary tuberculosis, whereas in tuberculous cervical lymphadenitis and otitis media the disease was regularly limited to the neck and the ear respectively. Preoperative microbiological testing pointed to a tuberculous origin in only 3 of the 18 patients, so that histological and microbiological examination of excision biopsy specimens was the most reliable test. As there was no apparent decrease in incidence over the 7 years, we conclude that tuberculosis remains an important differential diagnosis in ENT.

Role of surgery and chemotherapy for peripheral lymph node tuberculosis

A total of 105 patients with peripheral lymph node tuberculosis were treated by either surgical excision and chemotherapy or chemotherapy alone. The cervical nodes were affected in 98 patients, axillary nodes in four and inguinal nodes in three. Biopsy of the lymph nodes confirmed the diagnosis in all cases. Thirty-five patients who had sinus, ulcer or abscess underwent excision of the lymph nodes with drainage of the abscess, or resection of the sinus or ulcer. The remaining 70 patients received only chemotherapy. Chemotherapy in all patients consisted of isoniazid and ethambutol for 18 months. Of the 35 patients treated with surgery and chemotherapy, two had gaping wounds, one infection and one cellulitis of the face and neck. After 3 months, one patient had recurrence of the lymph node mass and one recurrence of a sinus; these were excised. Of the 70 patients treated only with chemotherapy, 13 were lost to follow-up. Four had non-healing wounds at the biopsy site, six wound infection and two sinus formation. Five of these patients had persistent lymph node masses, which were excised after 3 months. The remaining 52 patients had no recurrence.

Tracheoesophageal fistula caused by mycobacterial tuberculosis adenopathy

Tracheoesophageal fistulas resulting from a Mycobacterium tuberculosis infection are uncommon. We describe a patient with such a lesion that had the radiologic and clinic appearance of a malignant tracheoesophageal fistula. Use of an anterior cervical approach with one-stage esophageal repair along with tracheal resection and anastomosis allowed definitive diagnosis and treatment of this life-threatening complication.

Atypical tuberculosis in the pediatric patient: implications for the pediatric surgeon

Atypical species of mycobacteria (AMB) are now the most common cause of granulomatous lymphadenopathy. It is important for pediatric surgeons to be aware of this disease, because excision is the mainstay of therapy. We have reviewed the experience with this disease in Alberta by reviewing the records of the Provincial Laboratory of Public Health from 1979 to 1990. This facility reviews all tuberculosis cultures for the province. A total of 74 cases of infection caused by AMB were identified in patients under the age of 15. Complete records were available for 53 of these cases. These infections were characterized by a short history (11.2 weeks) of remarkably nontender regional lymphadenopathy (usually cervicofacial, 45/50) in young (average age, 13.6 months), caucasian (48/53) children. Attempts to treat these lesions by incision and drainage or drug therapy were unsuccessful (12/12 failed), whereas primary excision was successful in 33 of 37 cases. Secondary excisions were also successful in 16 of 16 cases where required. The annual rate of AMB over the study period was 1.21 cases per 100,000 children; the rate of M tuberculosis lymphadenopathy was 0.3 per 100,000. In the absence of specific risk factors for human tuberculosis (family history, native Indian or Asian ethnic origin) AMB is the most likely cause of prolonged painless lymphadenopathy and should be treated early by complete excision.

[Clinical issues of tuberculous cervical lymphadenitis: evaluation of 5 cases with packet formation]

Cervical lymphadenopathy with packet formation as the sole presentation of tuberculosis is very rarely seen in modern Japan. During the four years from 1987 to 1990, 5 cases of cervical scrofula with packet formation were treated with selective neck dissection followed by antituberculous chemotherapy at the ENT-department of Haibara General Hospital. Clinical evaluation of these cases suggested the following: 1) The physician must keep in mind that cervical scrofula should be included in the differential diagnosis of any neck masses, and malignant neck tumors particularly should be differentiated from cervical scrofula. 2) The treatment of cervical scrofula should be appropriate to the clinical stage diagnosed by CT or MRI. Recommended therapy for cervical scrofula with packet formation is selective neck dissection followed by antituberculous chemotherapy, which can shorten the period of treatment. 3) We present here a 22-year-old female from the Philippines with cervical scrofula and suggest that, in the future in Japan, tuberculosis may frequently be encountered in the immigrant population from the countries with high incidences of tuberculosis.

[Chronic specific cervicofacial lymphadenitis: the clinical and therapeutic considerations of a case of tubercular-origin submandibular adenopathy]

After a short review of the most recent literature on the topic, the paper reports a case of submandibular adenopathy of tubercular origin: the diagnostic difficulties which arose appear to be mainly correlated to the superimposed presence of chronic sialoadenitis. The clinical, diagnostic and therapeutic aspects of the case are discussed.

Massive tuberculous mesenteric lymphadenopathy

Abdominal tuberculosis accounts for 10% of all tuberculosis seen in Papua New Guinea. Nodal tuberculosis is usually associated with intestinal or peritoneal lesions. A case of massive tuberculous mesenteric lymphadenopathy with recurrent intestinal obstruction is presented here with a review of the relevant literature.

Six-month combination chemotherapy for cervical tuberculous lymphadenitis

A prospective study was undertaken to determine the effectiveness of a 6-month four-drug regimen in the treatment of 123 patients with cervical tuberculous lymphadenitis. The results showed that the disease was satisfactorily controlled with residual lymph nodes which did not necessitate further chemotherapy in 14.6% of patients at 3 years follow-up. Recurrence requiring further chemotherapy occurred in 3.3% of patients between 9 and 28 months. Wound sinuses occurred in 3.3% of patients and all healed with conservative treatment. The culture results and numbers of lymph nodes at presentation had no effect on outcome at 3 years. An excisional procedure was associated with a lower incidence of residual lymph nodes than an incisional biopsy. Minor gastrointestinal upset from drug treatment was common, but only 2.4% of patients needed a change of regimen. Six months of combination chemotherapy is adequate for the treatment of the disease.

[BCG-induced inflammation during childhood and in pregnancy. Additionally a contribution to BCG-induced necrotising cerebral arteritis]

In the third year of life of a girl vaccinated neonatally against tuberculosis an abscess of the associated lymph nodes appeared which contained acid-fast bacilli. After extirpation of the lymph nodes weeks later an intestinal BCG-dissemination was observed which seemed to be cured under a brief tuberculostatic therapy. At the age of 22 years a left sided hemiplegia due to aneurysms and thrombosis of 2 cerebral arteries was seen. At autopsy in the adventitia of the arteria basilaris macrophages were discovered which showed intracellular acid-fast bacilli. A paralysis of the oculomotor nerve appearing later was also caused by this brain lesion. Towards the end of a pregnancy a serious BCG-dissemination in the intestines relapsed. A healthy premature child was born. Massive tuberculostatic therapy was inefficient. The woman died in her 27th year of life. A defective function of the macrophages is suggested for the immunological abnormality.

[A resected case of mediastinal tuberculous lymphadenitis with pericostal tuberculosis]

A case of 22-year-old female with mediastinal tuberculous lymphadenitis and pericostal tuberculosis was reported. Her complaint was right chest pain and subcutaneous mass on the right chest wall. Chest contrast CT showed right paratracheal lymph node swelling with central low density area and surrounding rim enhancement, which has been reported as typical characteristics of mediastinal tuberculous lymphadenitis. Pigeon-egg sized subcutaneous mass with fluctuation was palpable on the right sternal border and the smear of its content showed acid-fast bacilli. In spite of two months therapy with antituberculous drugs, both masses were unchanged in size. The lesions resected surgically, were both encapsulated abscesses containing yellowish pus, and microscopic examination of these specimen disclosed the finding of tuberculosis. Mycobacterium tuberculosis was cultured from contents of both masses. After nine months of anti-tuberculous therapy, no sign of recurrence is observed until now. Both masses were discontinuous and the possibility of lymphangitic spread of organism was speculated as its etiology.

Huge prepericardial tuberculous abscess in a 2-year-old child

A 2-year-old girl presented with recurrent episodes of respiratory infection and was not thriving well. Investigation showed a huge cystic mass in the anterior mediastinum just in front of the heart. Exploration showed a massive cystic swelling with enormously thickened wall anterior to the heart. The mass was excised, and histopathology showed it to be of tuberculous origin.

Fine needle aspiration biopsy of tuberculous cervical lymphadenopathy

Fine needle aspiration biopsies of 42 histologically confirmed tuberculous cervical lesions were studied. Thirty-four patients had subsequent excision of cervical lymph nodes and eight had incision and drainage of cervical abscesses. All aspirates except two (which were inadequate) were satisfactory for diagnosis and contained inflammatory cells. Twenty-seven smears revealed cells typical of granulomatous lymphadenopathy, that is, epithelioid and multinucleated giant cells. Of all aspirates, 17 smears had bacteriological staining by Ziehl-Nielsen technique, nine of which (53%) were positive for acid-fast bacilli. An aspiration biopsy diagnosis of granulomatous or tuberculous cervical lymphadenopathy was made in 30 patients (71%). In regions where mycobacterial infection is common, the presence of granulomatous changes in lymph node aspirates is highly suggestive of tuberculosis. When the aspirates contain purulent material or when tuberculosis is suspected, staining and culture for mycobacteria should be performed. FNA biopsy is a sensitive, specific and cost-effective way to diagnose tuberculous cervical lymphadenopathy and is recommended.

Tuberculous cervical abscess: comparing the results of total excision against simple incision and drainage

In 40 patients with tuberculous cervical abscesses a prospective study was undertaken to determine the results of surgical treatment by either total excision or incision and drainage, together with 6 months of chemotherapy in both groups. While both procedures were well tolerated, the results showed that 17/22 (77 per cent) of those having a simple drainage procedure required a second operation to excise the residual infected lymph glands because of persistent sinus discharge, recurrent abscesses or enlarging lymphadenopathy. In contrast, 17/18 (94 per cent) of those having total excision as the primary procedure had no local ward problem afterwards. Most of the patients remained asymptomatic after completion of the chemotherapy but small painless lymph nodes might still be palpable during follow-up at 2 years.