Treatment of Non-Tuberculous Mycobacterial Lymphadenitis in Children
Complete surgical excision without chemotherapy is the definitive treatment for NTM cervical lymphadenitis in otherwise healthy children, achieving a 95-98% cure rate. 1, 2
Primary Treatment Approach
Excisional surgery alone (without antibiotics) is the gold standard for pediatric NTM cervical lymphadenitis. 1, 3 This recommendation is based on:
- Success rate of approximately 95-98% with complete excision alone 1, 2
- A randomized controlled trial demonstrating 96% cure rate with surgery versus only 66% with antibiotics (clarithromycin + rifabutin for ≥12 weeks) 4
- Meta-analysis showing complete excision had an adjusted cure rate of 98% compared to 73% for antibiotics and 70% for no intervention 2
Critical Surgical Principles
- Complete excision is essential—incomplete excision, incisional biopsy, or drainage alone leads to significantly worse outcomes 1, 3, 5
- Children who underwent incision and drainage (rather than complete excision) had 91% re-operation rate versus 30% for complete excision 5
- Incisional biopsy or drainage should be avoided as these procedures frequently result in sinus tract formation, chronic drainage, and persistent disease 1, 3, 5
When to Consider Medical Therapy Instead
Medical therapy with a clarithromycin-based multidrug regimen may be considered in specific high-risk scenarios: 1, 3
- High surgical risk (e.g., preauricular nodes with risk of facial nerve involvement) 1, 3
- Large lymph nodes ≥5 cm where complete excision is technically challenging 3
- Recurrent disease after initial surgical excision 1
Medical Therapy Regimen
When antibiotics are indicated, use: 1, 3
- Clarithromycin-based multidrug regimen (same as used for MAC pulmonary disease) 1
- Duration: 6-12 months of chemotherapy 1
- Never use anti-TB drugs alone without a macrolide—this approach has consistently failed and should be avoided 1, 3
Expected Outcomes with Medical Therapy
- Cure rates range from 66-73% with macrolide-based therapy 2, 4
- Some studies report 67% resolution with medical therapy alone, though this is substantially lower than surgery 6, 7
- 78% of patients experience adverse effects with clarithromycin + rifabutin, including 8% who must discontinue treatment 4
Critical Diagnostic Considerations Before Treatment
Tuberculosis Exclusion
If the child has a strongly positive PPD tuberculin skin test (≥15 mm) with granulomatous disease on biopsy: 1, 3
- Initiate anti-TB therapy immediately while awaiting lymph node culture results 1, 3
- This is especially critical if TB risk factors are present (positive family history, foreign-born child) 1, 3
- Discontinue anti-TB therapy if cultures are negative for mycobacteria, unless significant TB risk factors persist 1, 3
Specimen Handling
The excised lymph node must be sent for: 3
- Histopathologic analysis
- Mycobacterial cultures (both M. tuberculosis and NTM)
- Routine bacterial cultures
Surgical Complications
Facial nerve palsy occurs in approximately 10% of cases (2% permanent). 2 Other complications include: 4
- Staphylococcal wound infection in 12% of surgical patients 4
- Overall surgical complication rate of 28% 4
- Permanent grade 2 facial marginal branch dysfunction in 2% 4
Management of Treatment Failure
For recurrent disease after initial excision: 1, 3
- Second surgical procedure is usually performed 1
- Alternative: clarithromycin multidrug regimen for 6-12 months 1
Common Pitfalls to Avoid
- Never perform incisional biopsy or drainage alone—this leads to sinus formation and chronic drainage in the majority of cases 1, 3, 5
- Never use anti-TB drugs without a macrolide for NTM disease—this consistently fails 1, 3
- Do not mistake NTM lymphadenitis for bacterial infection—empiric antibiotics for presumed bacterial adenitis will fail and delay definitive treatment 3
- Do not use fine-needle aspiration alone for diagnosis—it frequently yields insufficient material and can delay definitive management 3