Surgical Therapy for Pediatric Patients with NTM Head and Neck Lesions Carries High Risk

What is the role of combined antimicrobial and surgical therapy for difficult-to-treat nontuberculous mycobacteria (NTM) lesions of the head and neck in children?

Background: NTM infections are a challenging cause of cervicofacial lymphadenitis in children. Fistula formation and spontaneous drainage often occur and can lead to significant disfiguration of the surrounding skin. Surgical infected lymph node excision is considered to be the most effective treatment, but this approach can be complicated by the infection location and its proximity to facial nerve branches.

Study design: Retrospective cohort review of 71 pediatric head and neck NTM lesions at a tertiary children’s hospital from 1999 to 2012.

Setting: Primary Children’s Hospital in Salt Lake City, Utah.

Synopsis: Mycobacterium avium-intracellulare was the most common mycobacterial species identified. NTM cervicofacial lymphadenitis diagnosis was established in the remaining patients by histology, acid-fast bacillus-positive culture, or both. Only one patient was successfully treated solely with antibiotics. Patients initially treated with incision and drainage and/or curettage, and who underwent incision and drainage and/or curettage in addition to medical therapy, experienced a high persistent infection rate (43%). Immediate resolution (85%) and complication rate (50%) were both high for patients treated with surgical excision alone. Between patients initially treated with surgical excision alone versus surgical excision with antibiotic therapy, recurrence and complication rates were similar (15% versus 11%, and 50% versus 66%, respectively). Surgical excision alone in high-risk regions resulted in successful removal in 88% of cases but with a high complication rate (47). None of the patients treated with surgical excision with multiple antibiotics for more than three months experienced persistent infection after treatment. However, complication rate was still high (70%), with the most common including medication adverse effects, marginal mandibular nerve weakness, and poor wound healing/scarring.

Bottom line: Surgical excision with or without medical therapy for NTM cervicofacial lymphadenitis in high-risk regions commonly resulted in marginal mandibular nerve dysfunction. High complication rates and a lack of proven best approaches suggest tailoring the approach to address the potential risks based on location and severity.

Citation: Gonzalez CD, Petersen MG, Miller M, Park AH, Wilson KF. Complex nontuberculous mycobacterial cervicofacial lymphadenitis: what is the optimal approach? Laryngoscope. 2016;126:1677-1680.