1
|
Koo EY, Maksimoski MT, Herron MM, Bhushan B, Reynolds MA, Katz BZ, Johnston DR, Rastatter JC, Maddalozzo J. Surgical management of parotid non-tuberculous mycobacteria lymphadenitis in children: A pediatric tertiary-care hospital's experience. Int J Pediatr Otorhinolaryngol 2021; 151:110960. [PMID: 34736012 DOI: 10.1016/j.ijporl.2021.110960] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 10/04/2021] [Accepted: 10/25/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Non-tuberculous mycobacteria (NTM) represents an important etiology of cervicofacial lymphadenitis (CFL) and skin/soft tissue infections in children. It can also affect the salivary glands, including the parotid gland, which is unique due to the presence of intra-salivary lymph nodes. There are no established guidelines for treatment of NTM CFL. NTM lymphadenitis was historically surgically treated; recently the literature supports initial medical treatment. Treatment decisions have been dependent on the extent of disease, preference of providers, and risk of surgical complications. The goal is to report our experience in surgical outcomes of NTM CFL with involvement of the parotid gland after pre-operative medical management. METHODS A retrospective case series of patients with NTM affecting the parotid gland at a tertiary care pediatric hospital between 2004 and 2020. RESULTS Seventy-two patients were referred for surgical evaluation of possible parotid NTM. Thirty-three patients underwent surgical excision. Fifteen patients were identified with presumed NTM infection involving the parotid gland. There were twelve females and three males with a mean age of 2.0 years (SD 1.55; range 1-6 days) at the time of surgery. All underwent surgical excision with parotidectomy. The most common pre-operative antimycobacterial therapy used was a combination of clarithromycin and rifampin. All 15 patients had pathological findings consistent with NTM infection (granulomatous lymphadenitis). Forty percent (n = 6) of patients had positive stains with acid-fast bacilli (AFB), with Mycobacterium avium as the most common species (n = 5). The majority of patients, 86.67% (n = 13), had complete resolution of infection after surgery. Clarithromycin and rifampin were the most common post-operative antimycobacterial treatment (mean 81.5 days, SD 110.14, range 2-411 days). The most common complication experienced was acute (<3 months) lower facial nerve paresis (40%, n = 6), but no patient had permanent facial paralysis. CONCLUSION AND RELEVANCE Parotidectomy is a safe and efficacious treatment in patients with NTM CFL affecting the parotid gland after incomplete resolution with antimycobacterial therapy. Further investigation to optimize duration of antimycobacterial treatment is necessary. We highlight the experience of a high-volume tertiary care pediatric hospital with surgical management of this disease.
Collapse
Affiliation(s)
- Elliot Y Koo
- Department of Otolaryngology - Head & Neck Surgery University of Illinois Chicago, Chicago, IL, USA; Division of Pediatric Otolaryngology Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Matthew T Maksimoski
- Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Division of Pediatric Otolaryngology Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Monica M Herron
- Division of Pediatric Otolaryngology Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Bharat Bhushan
- Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Division of Pediatric Otolaryngology Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Meredith A Reynolds
- Division of Pathology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Ben Z Katz
- Division of Infectious Disease, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Douglas R Johnston
- Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Division of Pediatric Otolaryngology Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Jeffrey C Rastatter
- Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Division of Pediatric Otolaryngology Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - John Maddalozzo
- Department of Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Division of Pediatric Otolaryngology Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| |
Collapse
|
2
|
Compton RA, Scott AR. Use of the facelift incision for excision of non-tuberculous mycobacterial lymphadenitis in children. Int J Pediatr Otorhinolaryngol 2019; 125:182-186. [PMID: 31344608 DOI: 10.1016/j.ijporl.2019.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 07/06/2019] [Accepted: 07/07/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To present cases of pediatric periparotid nontuberculous mycobacterial lymphadenitis excised through a facelift incision in order to review the advantages of this approach to parotidectomy. We also aim to discuss scenarios in which to forgo the facelift incision in favor of a traditional modified Blair incision. METHODS Retrospective series of seven consecutive patients who underwent parotidectomy for nontuberculous mycobacterial lymphadenitis between 2013 and 2018. RESULTS The series included three uses of the facelift incision and four uses of the modified Blair incision, which was specifically selected for cases of bulky lymphadenopathy anterior to the masseter muscle. All cases of Modified Blair incision involved circumferential dissection of the marginal mandibular branch of the facial nerve. The facelift incision permitted complete removal of disease in cases located posterior to the masseter as well as neck dissection as inferiorly as level III. Post-operatively, temporary marginal mandibular nerve weakness was seen in all cases of Modified Blair incision. Scar widening was most notable in patients who required skin excision or dermal curettage. CONCLUSION The facelift incision offers a more hidden scar. This may serve as an alternative approach to parotid surgery in young children with nontuberculous mycobacterial lymphadenitis, except in cases of bulky disease anterior to the masseter muscle for which optimal exposure of the marginal mandibular nerve via a modified Blair incision is warranted.
Collapse
Affiliation(s)
- Rebecca A Compton
- Tufts Medical Center, Department of Otolaryngology-Head and Neck Surgery, Boston, MA, USA
| | - Andrew R Scott
- Tufts Medical Center, Department of Otolaryngology-Head and Neck Surgery, Boston, MA, USA; Department of Pediatric Otolaryngology-Head and Neck Surgery and Pediatric Facial Plastic Surgery, Floating Hospital for Children at Tufts Medical Center, Boston, MA, USA.
| |
Collapse
|
3
|
Torretta S, Gaffuri M, Ibba T, Capaccio P, Marchisio P, Maruca A, Bosis S, Pignataro L. Surgical treatment of non-tuberculous mycobacterial lymphadenitis in children: Our experience and a narrative review. Int J Immunopathol Pharmacol 2019; 32:2058738418806413. [PMID: 30354841 PMCID: PMC6202736 DOI: 10.1177/2058738418806413] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Non-tuberculous mycobacterial lymphadenitis (NTML) accounts for about 95% of the cases of head-and-neck mycobacterial lymphadenitis, and its prevalence has been increasing in the Western world. The diagnostic work-up can be challenging, and differential diagnoses such as tuberculous and suppurative lymphadenitis need to be considered. It may, therefore, not be diagnosed until the disease is in a late stage, by which time it becomes locally destructive and is characterized by a chronically discharging sinus. The treatment options include a medical approach, a wait-and-see policy, and surgery, with the last being considered the treatment of choice despite the high risk of iatrogenic nerve lesions. The aim of this article is to provide an overview of pediatric, head-and-neck NTML based on the literature and our own experience, with particular emphasis on the impact and limitations of surgery.
Collapse
Affiliation(s)
- Sara Torretta
- 1 Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy.,2 Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Michele Gaffuri
- 2 Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Tullio Ibba
- 2 Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Pasquale Capaccio
- 2 Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,3 Department of Biomedical, Surgical and Odontoiatric Sciences, Università Degli Studi Di Milano, Milan, Italy
| | - Paola Marchisio
- 2 Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,4 Department of Pathophysiology and Transplantation, Università Degli Studi Di Milano, Milan, Italy
| | - Antonella Maruca
- 2 Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Samantha Bosis
- 2 Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Lorenzo Pignataro
- 1 Department of Clinical Sciences and Community Health, Università Degli Studi Di Milano, Milan, Italy.,2 Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| |
Collapse
|
4
|
Itano J, Ohashi K, Senoo S, Oda N, Nishii K, Taniguchi A, Miyahara N, Maeda Y, Kiura K. A case of axillary lymphadenitis caused by Mycobacterium intracellulare in an immunocompetent patient. Respir Med Case Rep 2019; 28:100947. [PMID: 31681532 PMCID: PMC6818345 DOI: 10.1016/j.rmcr.2019.100947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 10/12/2019] [Accepted: 10/12/2019] [Indexed: 11/04/2022] Open
Abstract
Axillary lymphadenitis caused by non-tuberculous mycobacteria is rare and has been reported in immunocompromised hosts. Herein, we report the case of a 67-year-old man without immunodeficiency who developed right axillary lymphadenitis caused by Mycobacterium intracellulare and showed a small nodular shadow in the left pulmonary apex. Biopsy of the right axillary lymph node revealed several epithelioid granulomas, and the culture of the lymph node aspirate yielded Mycobacterium intracellulare. The lymph node lesion and left lung apex shadow resolved spontaneously after careful outpatient monitoring. This case suggests that axillary lymphadenitis could be caused by Mycobacterium intracellulare in an immunocompetent patient.
Collapse
|
5
|
Willemse SH, Oomens MAEM, De Lange J, Karssemakers LHE. Diagnosing nontuberculous mycobacterial cervicofacial lymphadenitis in children: A systematic review. Int J Pediatr Otorhinolaryngol 2018; 112:48-54. [PMID: 30055739 DOI: 10.1016/j.ijporl.2018.06.034] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 06/14/2018] [Accepted: 06/15/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES Widespread controversy exists regarding correct diagnosing nontuberculous mycobacterial cervicofacial (NTM) lymphadenitis. This study intends to gather the available evidence with respect to diagnosing NTM cervicofacial lymphadenitis. METHODS A review protocol was developed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA)-statement (www.prisma-statement.org). A comprehensive search was performed in the bibliographic databases PubMed, Embase.com and Wiley/Cochrane Library. 10 Articles fulfilled the inclusion criteria and were included in the review. Assessing risk of bias of the articles was done using the revised Quality Assessment of Diagnostic Accuracy (QUADAS-2) tool. RESULTS This systematic review shows that diagnostic studies of high methodological quality are scarce. Diagnostic accuracy of polymerase chain reaction (PCR), culture, skin testing, auramine staining, Ziehl-Neelsen staining, and immunodiagnostic assays was studied. Culture sensitivity proved to be 41,8%, while polymerase chain reaction has a sensitivity of 71,6%. Both methods showed a specificity of 100%. Sensitivity of Immunodiagnostic assays ranged between 87,5% and 100% and specificity between 81% and 100%. Overall sensitivity of skin tests containing purified protein derivative (PPD-S) was 70% (95% CI [62%-78%]) with an overall specificity of 94% (95% CI [88%-100%]). CONCLUSIONS In patients with a high clinical suspicion for NTM cervicofacial lymphadenitis, a positive PPD-S skin is indicative for the diagnosis of NTM cervicofacial lymphadenitis. Either PCR or culture is necessary to confirm the diagnosis. Interferon-γ release assays with purified protein derivative stimulation appear to provide good sensitivity and specificity as a non-invasive pre-operative test, but the evidence is weak. More studies of high methodological quality are needed to validate the results of this systematic review.
Collapse
Affiliation(s)
- S H Willemse
- Department of Oral and Maxillofacial Surgery, Academic Medical Center, Amsterdam, The Netherlands.
| | - M A E M Oomens
- Department of Oral and Maxillofacial Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - J De Lange
- Department of Oral and Maxillofacial Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - L H E Karssemakers
- Department of Oral and Maxillofacial Surgery, Academic Medical Center, Amsterdam, The Netherlands; Department of Head and Neck Oncology and Surgery, Netherlands Cancer Institute/Antoni Van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| |
Collapse
|
6
|
Heffernan CB, McKeon MG, Molony S, Kawai K, Stiles DJ, Lachenauer CS, Kenna MA, Watters K. Does Clarithromycin Cause Hearing Loss? A 12-Year Review of Clarithromycin Therapy for Nontuberculous Mycobacterial Lymphadenitis in Children. Ann Otol Rhinol Laryngol 2018; 127:687-693. [PMID: 30032669 DOI: 10.1177/0003489418788112] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE(S) The objective was to describe the characteristics of hearing losses documented in patients treated with clarithromycin alone for nontuberculous mycobacterial NTM lymphadenitis in a pediatric tertiary care center over a 12-year period. METHODS An institutional review board (IRB) approval was obtained. A database search was performed using the ICD-10 diagnosis codes 31.0, 31.1, and 31.8 between January 2004 and January 2017. A REDCap database was created to record variables. Patients were included if they received clarithromycin alone and had, at the minimum, a baseline audiology assessment, and 1 further evaluation during treatment. Fisher's exact test was used to analyze categorical variables, and Wilcoxon rank sum test was used to analyze continuous variables. RESULTS A total of 167 patients with cervicofacial NTM were identified. Of them, 42 patients fulfilled inclusion criteria. Three children (7%) developed a hearing loss (HL) between 25 and 63 days after starting treatment. HL was unilateral in 2 children. HL persisted in 1 child following cessation of treatment. However, this patient had Rubinstein Taybi syndrome, limiting our ability to attribute the HL solely to clarithromycin. CONCLUSION We noted a 7% hearing loss rate in our series. Confounding issues, such as 1 patient with a syndrome potentially contributing to HL, and limitations to this study, including retrospective design and loss to follow-up, temper our ability to conclude that clarithromycin was the sole cause of these HL. However, enough supporting data for a role in clarithromycin causing HL exist that testing should be considered for patients undergoing long-term clarithromycin treatment.
Collapse
Affiliation(s)
- Colleen B Heffernan
- 1 Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA.,2 Department of Otolaryngology, Royal Hospital for Children, Glasgow, UK
| | - Mallory G McKeon
- 1 Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Sasha Molony
- 1 Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kosuke Kawai
- 1 Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA.,3 Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Derek J Stiles
- 1 Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA.,3 Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Catherine S Lachenauer
- 4 Division of Infectious Diseases, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Margaret A Kenna
- 1 Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA.,3 Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Karen Watters
- 1 Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, USA.,3 Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
7
|
Zimmermann P, Curtis N, Tebruegge M. Nontuberculous mycobacterial disease in childhood - update on diagnostic approaches and treatment. J Infect 2018. [PMID: 28646953 DOI: 10.1016/s0163-4453(17)30204-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Recent studies suggest that the incidence of nontuberculous mycobacterial infections in children may be increasing. Nontuberculous mycobacterial lymphadenitis, skin and soft tissue infection, and pulmonary disease each present unique challenges in relation to diagnosis and treatment. In this update, we critically review the recent literature on the epidemiology, clinical features, diagnostic approaches and treatment of nontuberculous mycobacterial disease in children. In addition, we outline key areas warranting further research.
Collapse
Affiliation(s)
- Petra Zimmermann
- Infectious Diseases Unit, Royal Children's Hospital Melbourne, Parkville, Australia; Department of Paediatrics, The University of Melbourne, Parkville, Australia; Murdoch Children's Research Institute, Parkville, Australia
| | - Nigel Curtis
- Infectious Diseases Unit, Royal Children's Hospital Melbourne, Parkville, Australia; Department of Paediatrics, The University of Melbourne, Parkville, Australia; Murdoch Children's Research Institute, Parkville, Australia
| | - Marc Tebruegge
- Department of Paediatrics, The University of Melbourne, Parkville, Australia; Academic Unit of Clinical & Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK; NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Global Health Research Institute, University of Southampton, Southampton, UK; Department of Paediatric Infectious Diseases & Immunology, Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK.
| |
Collapse
|
8
|
Naselli A, Losurdo G, Avanzini S, Tarantino V, Cristina E, Bondi E, Castagnola E. Management of nontuberculous mycobacterial lymphadenitis in a tertiary care children's hospital: A 20year experience. J Pediatr Surg 2017; 52:593-597. [PMID: 27614809 DOI: 10.1016/j.jpedsurg.2016.08.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 07/27/2016] [Accepted: 08/13/2016] [Indexed: 11/18/2022]
Abstract
PURPOSE Nontuberculous mycobacteria are uncommon cause of chronic cervicofacial lymphadenitis in healthy children. We describe clinical features and management strategies of cervicofacial nontuberculous mycobacterium lymphadenitis in a tertiary pediatric hospital. METHODS Retrospective analysis of medical records of children discharged from 1992 to 2014 with a diagnosis of cervicofacial nontuberculous mycobacterium was made. Diagnosis certainty was based on microhistological investigations. Clinical stage was evaluated according to lymph node size and presence of fistulas. Successful therapy was defined by the regression of the lymph node enlargement (>75%) or complete surgical excision without relapse. RESULTS Cervicofacial nontuberculous mycobacterium was diagnosed in 33 patients. Complete excision was performed in 73% of cases primarily observed in our hospital, while 83% of those referred from other hospitals required further surgical treatment. No case of relapse was observed after one year of follow-up. CONCLUSIONS We recommend surgical approach as the first therapeutic option in the management of cervicofacial nontuberculous mycobacterium lymphadenitis. LEVELS OF EVIDENCE Prognosis and Retrospective Study - Level II.
Collapse
Affiliation(s)
- Aldo Naselli
- Infectious Diseases Unit, Istituto Giannina Gaslini, Ospedale Pediatrico IRCCS, Genova, Italy
| | - Giuseppe Losurdo
- Infectious Diseases Unit, Istituto Giannina Gaslini, Ospedale Pediatrico IRCCS, Genova, Italy
| | - Stefano Avanzini
- Pediatric Surgery Unit, Istituto Giannina Gaslini, Ospedale Pediatrico IRCCS, Genova, Italy
| | - Vincenzo Tarantino
- Otorhinolaryngology Unit, Istituto Giannina Gaslini, Ospedale Pediatrico IRCCS, Genova, Italy
| | - Emilio Cristina
- Infectious Diseases Unit, Istituto Giannina Gaslini, Ospedale Pediatrico IRCCS, Genova, Italy
| | - Elisabetta Bondi
- Infectious Diseases Unit, Istituto Giannina Gaslini, Ospedale Pediatrico IRCCS, Genova, Italy
| | - Elio Castagnola
- Infectious Diseases Unit, Istituto Giannina Gaslini, Ospedale Pediatrico IRCCS, Genova, Italy.
| |
Collapse
|
9
|
Haimi-Cohen Y, Markus-Eidlitz T, Amir J, Zeharia A. Long-term Follow-up of Observation-Only Management of Nontuberculous Mycobacterial Lymphadenitis. Clin Pediatr (Phila) 2016; 55:1160-4. [PMID: 26603584 DOI: 10.1177/0009922815617972] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
A total of 21 children with clinically and microbiologically proven craniofacial nontuberculous mycobacterial lymphadenitis managed by observation only at a tertiary medical center in 1993-2005 were evaluated for scar parameters at least 2 years after diagnosis. Parents completed a satisfaction questionnaire. Median follow-up time from presentation was 6.8 years (range = 2.3-16.9 years). In all, 18 patients showed scar formation, for a total of 26 scars; 21 scars (81%) had a maximal length of ≤3 cm. Vascularity was normal in 20 scars (77%), and pigmentation was normal in 18 (69%); 21 scars (81%) had a normal to only mildly uneven surface. Although 8 parents (44%) reported that the presence of the scar disturbed them, all responders but one (94%) expressed overall contentment of observation only as a conceivable management alternative. In conclusion, an observation-only approach to craniofacial nontuberculous mycobacterial lymphadenitis is associated with an acceptable outcome and may be an alternative to patients who wish to avoid surgery.
Collapse
Affiliation(s)
- Yishai Haimi-Cohen
- Tel Aviv University, Tel Aviv, Israel Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Tal Markus-Eidlitz
- Tel Aviv University, Tel Aviv, Israel Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Jacob Amir
- Tel Aviv University, Tel Aviv, Israel Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Avraham Zeharia
- Tel Aviv University, Tel Aviv, Israel Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| |
Collapse
|
10
|
Gonzalez CD, Petersen MG, Miller M, Park AH, Wilson KF. Complex nontuberculous mycobacterial cervicofacial lymphadenitis: What is the optimal approach? Laryngoscope 2015; 126:1677-80. [PMID: 26372159 DOI: 10.1002/lary.25603] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2015] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS Assess the role of combined antimicrobial and surgical therapy for difficult-to-treat nontuberculous mycobacteria (NTM) lesions of the head and neck in children. STUDY DESIGN Retrospective cohort. METHODS Retrospective review of pediatric head and neck NTM lesions at a tertiary children's hospital from 1999 to 2012. RESULTS Seventy-one children were diagnosed with NTM lesions. Age of presentation ranged between 7 and 204 months of age. Most patients (62%) had multiple lesions. Treatments included incision and drainage, curettage, antibiotics, excision, and any combination of surgery and antibiotics. Upon initial presentation, the most common treatment was surgical excision alone (n = 34) with a high complication rate (50%). In 18 cases, patients were initially treated with a combination of antibiotics and surgical excision due to the extent or location of the lesion(s). Complication rate in these patients was also high (67%). The most common complications in surgically excised NTM lesions included temporary or persistent facial nerve dysfunction (24.6%), poor wound healing/scarring (10.8%), and Frey's syndrome (6.2%). CONCLUSIONS Surgical excision with or without medical therapy for NTM cervicofacial lymphadenitis in high-risk regions commonly resulted in marginal mandibular nerve dysfunction (24.6%). Postoperative facial nerve weakness generally resolved within a year. High rates of complications and a lack of proven best approaches suggest tailoring the approach to address the potential risks in that particular patient based on location and severity. LEVEL OF EVIDENCE 4 Laryngoscope, 126:1677-1680, 2016.
Collapse
Affiliation(s)
| | | | - Matthew Miller
- Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa City, Iowa
| | - Albert H Park
- Division of Otolaryngology-Head and Neck Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Kevin F Wilson
- Division of Otolaryngology-Head and Neck Surgery, University of Utah, Salt Lake City, Utah, USA
| |
Collapse
|
11
|
Abstract
The differential diagnosis in pediatric lymphadenopathy includes bacterial, viral, fungal, and idiopathic causes. A systematic approach to patient evaluation is necessary because the differential diagnosis, presentation, and work up must consider infectious, immunologic, neoplastic, and idiopathic disorders. A thorough history and examination are vital to determining the diagnosis and ruling out a malignant process.
Collapse
Affiliation(s)
- Edward B Penn
- Department of Otolaryngology, Monroe Carell Jr Children's Hospital, Vanderbilt University, 2200 Children's Way, DOT 7, Nashville, TN 37232, USA.
| | - Steven L Goudy
- Department of Otolaryngology, Monroe Carell Jr Children's Hospital, Vanderbilt University, 2200 Children's Way, DOT 7, Nashville, TN 37232, USA
| |
Collapse
|
12
|
Zimmermann P, Tebruegge M, Curtis N, Ritz N. The management of non-tuberculous cervicofacial lymphadenitis in children: A systematic review and meta-analysis. J Infect 2015; 71:9-18. [PMID: 25727993 DOI: 10.1016/j.jinf.2015.02.010] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 02/16/2015] [Accepted: 02/20/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Cervicofacial lymphadenitis is the most common manifestation of infection with non-tuberculous mycobacteria (NTM) in immunocompetent children. Although complete excision is considered standard management, the optimal treatment remains controversial. This study reviews the evidence for different management options for NTM lymphadenitis. METHODS A systematic literature review and meta-analysis were performed including 1951 children from sixty publications. Generalised linear mixed model regressions were used to compare treatment modalities. RESULTS The adjusted mean cure rate was 98% (95% CI 97.0-99.5%) for complete excision, 73.1% (95% CI 49.6-88.3%) for anti-mycobacterial antibiotics, and 70.4% (95% CI 49.6-88.3%) for 'no intervention'. Compared to 'no intervention', only complete excision was significantly associated with cure (OR 33.1; 95% CI 10.8-102.9; p < 0.001). Complete excision was associated with a 10% risk of facial nerve palsy (2% permanent). 'No intervention' was associated with delayed resolution. CONCLUSIONS Complete excision is associated with the highest cure rate in NTM cervicofacial lymphadenitis, but also had the highest risk of facial nerve palsy. In the absence of large, well-designed RCTs, the choice between surgical excision, anti-mycobacterial antibiotics and 'no intervention' should be based on the location and extent of the disease, and acceptability of prolonged time to resolution.
Collapse
Affiliation(s)
- Petra Zimmermann
- Infectious Diseases Unit, University Children's Hospital, University of Berne, 3010 Berne, Switzerland.
| | - Marc Tebruegge
- Academic Unit of Clinical & Experimental Sciences, Faculty of Medicine, and Institute for Life Sciences, University of Southampton, Southampton, UK; Department of Paediatrics, The University of Melbourne, and Murdoch Children's Research Institute, The Royal Children's Hospital Melbourne, Parkville, 3052, Australia.
| | - Nigel Curtis
- Department of Paediatrics, The University of Melbourne, and Murdoch Children's Research Institute, The Royal Children's Hospital Melbourne, Parkville, 3052, Australia.
| | - Nicole Ritz
- Department of Paediatrics, The University of Melbourne, and Murdoch Children's Research Institute, The Royal Children's Hospital Melbourne, Parkville, 3052, Australia; Infectious Diseases Unit, University Children's Hospital, University of Basel, 4031 Basel, Switzerland.
| |
Collapse
|
13
|
Iro H, Zenk J. Salivary gland diseases in children. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2014; 13:Doc06. [PMID: 25587366 PMCID: PMC4273167 DOI: 10.3205/cto000109] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Salivary gland diseases in children are rare, apart from viral-induced diseases. Nevertheless, it is essential for the otolaryngologist to recognize these uncommon findings in children and adolescents and to diagnose and initiate the proper treatment. The present work provides an overview of the entire spectrum of congenital and acquired diseases of the salivary glands in childhood and adolescence. The current literature was reviewed and the results discussed and summarized. Besides congenital diseases of the salivary glands in children, the main etiologies of viral and bacterial infections, autoimmune diseases and tumors of the salivary glands were considered. In addition to the known facts, new developments in diagnostics, imaging and therapy, including sialendoscopy in obstructive diseases and chronic recurrent juvenile sialadenitis were taken into account. In addition, systemic causes of salivary gland swelling and the treatment of sialorrhoea were discussed. Although salivary gland diseases in children are usually included in the pathology of the adult, they differ in their incidence and sometimes in their symptoms. Clinical diagnostics and especially the surgical treatment are influenced by a stringent indications and a less invasive strategy. Due to the rarity of tumors of the salivary glands in children, it is recommended to treat them in a specialized center with greater surgical experience. Altogether the knowledge of the differential diagnoses in salivary gland diseases in children is important for otolaryngologists, to indicate the proper therapeutic approach.
Collapse
Affiliation(s)
- Heinrich Iro
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Erlangen, University of Erlangen-Nuremberg, Germany
| | - Johannes Zenk
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Erlangen, University of Erlangen-Nuremberg, Germany
| |
Collapse
|
14
|
[Surgical treatment of children with nontuberculous mycobacteria cervical lymphadenitis]. HNO 2014; 62:570-4. [PMID: 25008272 DOI: 10.1007/s00106-014-2881-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Persistent cervical lymphadenopathy is the typical clinical manifestation of nontuberculous mycobacterial (NTM) infection in otherwise healthy children 1-5 years of age. A positive NTM culture or PCR is necessary to proof the diagnosis. In the case of localized disease, cervical lymphadenectomy simultaneously serves both diagnosis and therapy. A typical complication of surgical treatment, i.e. incision, puncture or excision, is the formation of a fistula, which then requires further surgical intervention. In the case of an unconfirmed diagnosis, the extent of the initial surgical intervention remains unclear. PATIENTS AND METHODS On the basis of this diagnosis, 17 operations were performed in 10 children under the age of 7 years (8 female, 2 male; age 17 months to 5 years, median 36 months) in the Charité ENT clinics between 2009 and 2012. Clinical course and diagnostics, as well as the results of therapies and treatments were retrospectively analysed. RESULTS Duration of anamnesis prior to initial surgery was 2-30 weeks (mean 10.4 weeks). A second intervention was performed in 7 out of 10 patients. No patient developed recurrent disease after selective cervical lymphadenectomy. The clinical course of 1 patient was complicated by a cefuroxime-responsive Staph. aureus superinfection. A second patient experienced transient accessory nerve paresis after lymphadenectomy, which resolved 2 months after the second surgery. CONCLUSION In case of persistent cervical lymphadenopathy a complete diagnostic workup is necessary. If lymphadenopathy continues to persist 1 month after a 10-day course of broad-spectrum antibiotics, a selective cervical lymphadenectomy should be performed. In order to avoid the development of fistulae and avoid secondary surgical procedures, incision, drainage and puncture should be deferred.
Collapse
|
15
|
Deichmueller CMC, Emmanouil K, Welkoborsky HJ. Atypical mycobacteriosis in children: a diagnostic and therapeutic challenge. Eur Arch Otorhinolaryngol 2014; 272:2425-31. [DOI: 10.1007/s00405-014-3160-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Accepted: 06/15/2014] [Indexed: 11/24/2022]
|
16
|
Ahmed HG, Elmubasher MB, Salih RAA, Elhussein GEMO, Ashankyty IMA. Fine Needle Aspiration Cytopathology of Pediatric Lympha denopathy among Sudanese Children. Asian Pac J Cancer Prev 2013; 14:4359-63. [DOI: 10.7314/apjcp.2013.14.7.4359] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
|
17
|
Recomendaciones de la Sociedad Española de Infectología Pediátrica sobre el diagnóstico y tratamiento de las adenitis por micobacterias no tuberculosas. An Pediatr (Barc) 2012; 77:208.e1-208.e12. [DOI: 10.1016/j.anpedi.2012.02.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 02/22/2012] [Indexed: 12/28/2022] Open
|
18
|
Parker NP, Scott AR, Finkelstein M, Tibesar RJ, Lander TA, Rimell FL, Sidman JD. Predicting Surgical Outcomes in Pediatric Cervicofacial Nontuberculous Mycobacterial Lymphadenitis. Ann Otol Rhinol Laryngol 2012; 121:478-84. [DOI: 10.1177/000348941212100709] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives: We examined surgical outcomes in children with cervicofacial nontuberculous mycobacterial lymphadenitis and attempted to identify predictors of complications. Methods: A retrospective chart review from 2 tertiary pediatric centers was used to identify 11 presentation or operative variables (age at surgery, gender, symptom duration, pain, violaceous skin changes, skin breakdown, fluctuance, purified protein derivative positivity, operative procedure, use of nerve integrity monitoring, and use of skin flap advancement) and to compare these to 5 postoperative complications (facial nerve dysfunction [paresis or paralysis], poor scarring, recurrence, wound infection, and wound dehiscence without infection). Results: The 45 patients analyzed for presentation or operative variables (28 female, 17 male; average age, 31.2 months) typically presented with painless masses averaging 8.2 weeks in duration, along with violaceous skin changes in 29 of the 45 cases (64%) and skin breakdown in 9 cases (20%). The surgical procedures included parotidectomy with or without selective lymphadenectomy in 38 of the 45 cases (84%) and lymphadenectomy alone in 7 cases (16%). Skin resection and cervicofacial advancement flap reconstruction was performed in 20 cases (44%). Nerve integrity monitoring was utilized in 32 cases (71%). In the 44 patients analyzed for postoperative complications, we found facial nerve paresis in 14 (31.8%), poor scarring in 9 (20.5%), wound infection in 6 (13.6%), recurrence in 4 (9.1%), and facial nerve paralysis in 2 (4.5%). Nine of the 14 cases (64.3%) of initial facial nerve paresis resolved. At final follow-up, facial nerve paresis persisted in 5 of the 14 children (35.7%) with initial postoperative paresis and in 1 of the 2 children (50.0%) with initial postoperative paralysis. Facial nerve paralysis persisted in the other child with initial postoperative paralysis. Overall, 6 of these 7 patients (85.7%) with persistent facial nerve dysfunction had follow-up of less than 1 month. All transient and permanent facial nerve dysfunction was in the distribution of the marginal mandibular nerve only. No statistically significant predictors of complications were identified. Conclusions: We report acceptable but not insignificant rates of marginal mandibular distribution facial nerve injury, poor scarring, wound infection, and recurrence following resection of cervicofacial nontuberculous mycobacterial lymphade nitis in children that must be discussed with patients and parents before operation. No presentation or operative variables predicted the complications.
Collapse
|
19
|
Clark JE. Nontuberculous lymphadenopathy in children: using the evidence to plan optimal management. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2012; 719:117-21. [PMID: 22125039 DOI: 10.1007/978-1-4614-0204-6_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
There is no evidence that drug treatment improves healing more rapidly or is associated with an improved cosmetic outcome compared to spontaneous resolution, and no studies have related therapy and outcome to mycobacterial species and susceptibility. It is interesting that widespread and accepted use of drug treatment has developed with no good evidence that drugs facilitate healing[36]. It is therefore essential, given spontaneous healing will occur, that any future studies compare drug treatment with spontaneous resolution.In conclusion there is good evidence that excision of nontuberculous mycobacterial lymphadenopathy is usually curative and should be performed where possible. Where lesions are too large or too difficult to surgically excise, alternatives could include de-bulking with incision and drainage or curettage, recognising that treated this way lesions will be slow to heal. Until there is evidence about the efficacy of antimycobacterial drug treatment it should not be used routinely, though it may be considered in extensive, complex disease. Also, there is no evidence to suggest that antimycobacterial drugs confer an additional benefit when the lesion is excised.
Collapse
|
20
|
Lindeboom JA. Surgical Treatment for Nontuberculous Mycobacterial (NTM) Cervicofacial Lymphadenitis in Children. J Oral Maxillofac Surg 2012; 70:345-8. [DOI: 10.1016/j.joms.2011.02.034] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2010] [Revised: 02/01/2011] [Accepted: 02/03/2011] [Indexed: 11/15/2022]
|
21
|
Penn R, Steehler MK, Sokohl A, Harley EH. Nontuberculous mycobacterial cervicofacial lymphadenitis--a review and proposed classification system. Int J Pediatr Otorhinolaryngol 2011; 75:1599-603. [PMID: 22014500 DOI: 10.1016/j.ijporl.2011.09.018] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Revised: 09/15/2011] [Accepted: 09/19/2011] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe a clinical staging system for nontuberculous mycobacterial (NTM) cervicofacial lymphadenitis that has both diagnostic and therapeutic implications. METHODS A Medline database search was performed using key words "nontuberculous mycobacteria". All articles pertaining to nontuberculous mycobacterial cervicofacial lymphadenitis were reviewed for data evaluation regarding diagnosis and treatment methodologies. RESULTS Nontuberculous cervicofacial lymphadenitis infections pass through distinctly segmented clinical phases. In Stage I, a painless mass presents with notable increase in vascularity. Stage II is characterized by liquefaction of the affected lymph node, causing the mass to appear fluctuant. Significant skin changes characterize Stage III, whereby overlying skin may develop violaceous discoloration and become notably thinner, or parchment-like, with a "shiny" appearance. During Stage IV, the lesion fistulizes to the skin surface causing a draining wound. CONCLUSIONS While nontuberculous mycobacterial cervicofacial lymphadenitis has typically been thought of as a surgical disease, further characterization is warranted. We present a new classification system for appraising the clinical stages of nontuberculous mycobacterial cervicofacial lymphadenitis that may be used as part of a greater approach to disease management: (1) after other causes have been ruled out, the possibility of a tuberculous scrofula must be eliminated, and the degree of diagnostic suspicion must be categorized; (2) the clinical stage of the infection can be determined using the classification system described; and (3) a stage-specific treatment may be chosen based on the individual patient.
Collapse
Affiliation(s)
- Renee Penn
- Department of Otolaryngology - Head and Neck Surgery, South Pasadena Cancer Center, 209 Fair Oaks Avenue, South Pasadena, CA 91030, United States
| | | | | | | |
Collapse
|
22
|
Lindeboom JA. Conservative wait-and-see therapy versus antibiotic treatment for nontuberculous mycobacterial cervicofacial lymphadenitis in children. Clin Infect Dis 2010; 52:180-4. [PMID: 21288841 DOI: 10.1093/cid/ciq070] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In this explorative study, 50 children with microbiologically confirmed nontuberculous mycobacterial cervicofacial lymphadenitis were randomized to either receive antibiotic therapy or follow a conservative wait-and-see approach. Our primary objective was to assess the time for all infected lymph nodes to heal in patients after the nonantibiotic, wait-and-see treatment, compared with patients after a 12-week course of clarithromycin and rifabutin. METHODS Fifty children (19 boys and 31 girls) with a polymerase chain reaction (PCR)- or culture-confirmed diagnosis of cervicofacial nontuberculous mycobacterial infection were included in our study. Twenty-five children were randomized to receive antibiotic therapy and 25 to be given a wait-and-see approach. RESULTS The median age of the children was 35 months (range, 14-114 months). The median time to resolution of the disease for the antibiotic group was 36 weeks, compared with 40 weeks for the wait-and-see group. Adverse effects of antibiotic therapy included gastrointestinal complaints, fever, and reversible extrinsic tooth discoloration. CONCLUSION In children with an advanced stage of nontuberculous mycobacterial cervicofacial lymphadenitis, we observed no significant differences in median healing time between the wait-and-see group and the group receiving clarithromycin and rifabutin antibiotic therapy.
Collapse
Affiliation(s)
- Jerome A Lindeboom
- Department of Oral and Maxillofacial Surgery, Academic Medical Center, Amsterdam University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands.
| |
Collapse
|