International Journal of Pediatric Otorhinolaryngology 75 (2011) 1599–1603

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International Journal of Pediatric Otorhinolaryngology

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Nontuberculous mycobacterial cervicofacial lymphadenitis—A review and

proposed classification system§
Renee Penn a, Matthew K. Steehler b,*, Alex Sokohl c, Earl H. Harley b
a
Department of Otolaryngology – Head and Neck Surgery, South Pasadena Cancer Center, 209 Fair Oaks Avenue, South Pasadena, CA 91030, United States
b
Department of Otolaryngology – Head and Neck Surgery, Georgetown University Hospital, 3800 Reservoir Drive NW, Washington, DC 20007, United States
c
Department of Otolaryngology – Head & Neck Surgery, Medical University of South Carolina, 135 Rutledge Avenue, MSC 550, Charleston, SC 29425, United States

A R T I C L E I N F O A B S T R A C T

Article history: Objective: To describe a clinical staging system for nontuberculous mycobacterial (NTM) cervicofacial
Received 13 July 2011 lymphadenitis that has both diagnostic and therapeutic implications.
Received in revised form 15 September 2011 Methods: A Medline database search was performed using key words ‘‘nontuberculous mycobacteria’’.
Accepted 19 September 2011
All articles pertaining to nontuberculous mycobacterial cervicofacial lymphadenitis were reviewed for
Available online 19 October 2011
data evaluation regarding diagnosis and treatment methodologies.
Results: Nontuberculous cervicofacial lymphadenitis infections pass through distinctly segmented
Keywords:
clinical phases. In Stage I, a painless mass presents with notable increase in vascularity. Stage II is
Nontuberculous
Atypical
characterized by liquefaction of the affected lymph node, causing the mass to appear fluctuant.
Mycobacteria Significant skin changes characterize Stage III, whereby overlying skin may develop violaceous
Cervicofacial lymphadenopathy discoloration and become notably thinner, or parchment-like, with a ‘‘shiny’’ appearance. During Stage
Cervicofacial lymphadenitis IV, the lesion fistulizes to the skin surface causing a draining wound.
Scrofula 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.
ß 2011 Elsevier Ireland Ltd. All rights reserved.

1. Introduction 2. Materials and methods

Infection due to nontuberculous mycobacterium (NTM) is a
common cause of chronic lymphadenopathy of the head and neck
in immunocompetent children [1]. The clinical course of NTM
lymphadenopathy is known to be varied in its presentation. We
propose a diagnostic classification system for the clinical stages of
disease which also provides therapeutic implications. Categorizing
NTM cervicofacial lymphadenitis allows for a stage-appropriate
intervention with a consistent standard of care.
A Medline database search was performed using key words
‘‘nontuberculous mycobacteria’’ and ‘‘atypical mycobacteria’’. All
articles pertaining to NTM cervicofacial lymphadenitis were
reviewed for data evaluation regarding diagnosis and treatment
methodologies, with a concentration on those pertaining to the
pediatric population.
3. Results

3.1. Background

Nontuberculous mycobacteria are ubiquitous organisms that

§
Material from this submission has been presented as a poster at the American
Academy of Otolaryngology, Head and Neck Surgery Annual Meeting, September
17–21, 2006; Toronto, Canada and updated with current literature.
* Corresponding author at: 4200 Cathedral Ave. NW Apt. 515, Washington, DC
20016. Tel.: +1 814 450 0742; fax: +1 202 444 1312.
E-mail address: mattsteehler@yahoo.com (M.K. Steehler).
typically reside in soil. Nonetheless, there are endemic geographic
areas, namely, the midwestern and southwestern United States,
where these pathogens are more common. The organisms are most
likely ingested, with routes including contaminated animal
products and natural water sources. In children, organisms may
enter the body through lesions in the oral mucosa. This may

0165-5876/$ – see front matter ß 2011 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijporl.2011.09.018
1600 R. Penn et al. / International Journal of Pediatric Otorhinolaryngology 75 (2011) 1599–1603
explain why the cervicofacial lymph nodes are those most
commonly affected by NTM infections. Unlike tuberculosis (TB),
human-to-human transmission has not been demonstrated in
cases of NTM, and keeping infected children out of school for
isolation precautions is considered unnecessary.
Nontuberculous mycobacteria are robust organisms with a
protective lipid-based capsule that is resistant to decolorization by
acid-alcohol and hence routine histological staining. As such, they
are deemed to be acid-fast bacilli (AFB) and require specialized
staining processes. While typical culture of biopsy specimens can
take between 2 and 4 weeks for most species, DNA probes and
polymerase chain reaction techniques allow for more rapid
identification [2]. Acid-fast staining alone may provide a confir-
mation of the presumed diagnosis in the setting of a negative PPD.
The incriminated species often include Mycobacterium avium-
intracellulare, Mycobacterium scrofulaceum and Mycobacterium
kansasii.
3.2. Clinical course and diagnosis
Children between the ages of 1–5 years are at greatest risk for
infection. The most commonly affected nodes include the
jugulodigastric, submandibular, parotid/pre-auricular, submental,
and posterior triangle lymph nodes. The size of the infected lymph
node can range from 1 to 6 cm and is typically non-tender. Signs or
symptoms consistent with systemic illness (fever, malaise) may
occur, though the child more commonly is asymptomatic [2]. Early
in the course of the infection, children often undergo initial
evaluation, and the mass can easily be attributed to an incidental
upper respiratory tract infection or other causes of reactive
lymphadenopathy. Frequently, antibiotics are prescribed at this
time. It is usually persistence of the mass despite antibiotics that
increases concern. Panesar et al. reported a delay of 8–12 weeks in
44% of cases before the patient is referred for evaluation by a
specialist [3]. Olson and Kennedy independently found that up to
52 weeks may pass prior to referral, but on average the
cervicofacial adenopathy was present for 12 weeks prior to
initiating definitive treatment [4,5].
Following enlargement, the affected lymph node(s) may
liquefy, resulting in a fluctuant lesion, a finding likely consistent
with necrosis often found in the granulomatous centers of these
lesions (Fig. 1). Evans et al. described the granulomatous changes
of the affected lymph nodes as seen by histological examination.
They reported a relatively consistent histological appearance of
stellate or serpiginous areas of necrosis with nuclear debris and
neutrophils scattered throughout the caseous foci [6].
Soon thereafter, overlying skin changes may occur, which often
include violaceous skin discoloration. The surrounding epidermis
is likely to thin, resulting in parchment-like transformation. It is
postulated that these skin changes are due to inflammatory
mediators recruited to the region by the formation of necrotic and
liquefied debris. This stage in the clinical course can be dramatic
and is often instrumental in specialist referral, representing 76–
80% of patients presenting to an otolaryngology specialist [7,8].
Finally, the liquefied and necrotic collection fistulizes to the
skin, representing the final stage of the disease process in
otherwise immunocompetent children. It is the presenting stage
in 9–52% of the affected pediatric population and is the most
concerning regarding cosmetic outcome [3,7,8]. The frequency of
individuals presenting at various stages of infection is outlined in
Table 1.
3.3. Diagnosis
Contrast-enhanced computed tomography (CT) imaging can be
helpful for diagnosis. Characteristic features of NTM lymphadenitis
Fig. 1. Caseating granuloma: cellular border and necrotic center.
distinguish this infectious process from other forms of bacterial
adenitis, namely, asymmetrical adenopathy with contiguous, low-
density ring-enhancement. Necrotic foci with skin and subcuta-
neous tissue involvement are not uncommon. However, inflam-
matory changes involving the subcutaneous tissue, such as fat-
stranding, are notably absent [9–11].
Diagnostic efforts will often include attempts to rule out a
tuberculous cause of infection. Obtaining a thorough travel and
contact history is mandatory. Purified protein derivative (PPD) as
well as nontuberculous mycobacterial antigens may be injected
intra-dermally for testing. Chest X-ray may be indicated if anergy
to intra-dermal testing is suspected and should be negative if
cervical lymphadenitis is due to NTM infection.
PPD testing has been shown to produce variable results. Tunkel
described a 40% positive reaction (>10 mm reactive zone), 10%
‘‘intermediate’’ response (5–9 mm), and a 50% negative test rate
[6]. Panesar et al. described a 4% positive reaction, a 51%
intermediate test rate, and a 45% negative read on PPD skin
testing [3]. Wei et al. reported 67% positive (any induration
between 5 mm and 15 mm) and 33% negative reactions [12].
Similarly, Rahal et al. described mixed results: 26% positive and
74% negative reactions, with no reported intermediate responses.
However, Rahal et al. reported positive NTM skin antigen testing in
13 of 15 patients with a definitive diagnosis of NTM infection [8].
NTM-specific skin antigen testing is not described by other authors
on the subject. While these results suggest NTM-specific skin
antigen testing to be a useful diagnostic measure, the lack of
Table 1
Frequency of presenting clinical features.
Presenting symptom Frequency
Cervicofacial mass Rahal et al. [8]: n = 25/50 (50%)
with erythema
Fluctuance Frequency not reported
Overlying skin changes Rahal et al. [8]: n = 15/50 (35%)
Tunkel [7]: n = 19/25 (76%) –
may include erythema
Mandell et al. [16]: n = 17/34 (50%) –
including erythema changes
Panesar et al. [3]: n = 24/79 (30%) –
may include erythema
Fistula Schaad et al. [13]: n = 33/363 (9%)
Rahal et al. [8]: n = 10/50 (20%)
Tunkel [7]: n = 13/25 (52%)
Panesar et al. [3]: n = 12/70 (15%) –
includes dermal necrosis
 R. Penn et al. / International Journal of Pediatric Otorhinolaryngology 75 (2011) 1599–1603
Table 2
Diagnostic categories for cervicofacial NTM infections [4].
Category Criteria
I Culture positive for NTM
II ‘‘Typical Clinical Picture’’
AFB found on smear or special stains of tissue
Culture negative
III ‘‘Typical Clinical Picture’’
Positive tuberculin skin test
AFB not found
Culture negative
IV ‘‘Typical Clinical Picture’’
Histology compatible with NTM infection
Negative skin test (PPD)
AFB not found
Culture negative
NTM: nontuberculous mycobacteria; AFB: acid-fast bacilli; PPD: purified protein
derivative.
general availability, and thus practicality, of this test in the primary
care setting renders it a less useful option.
Many parameters are likely to contribute to the diagnosis of
NTM cervical lymphadenitis, but the relative importance of
eliminating tuberculous mycobacteria as a source for infection
cannot be over-emphasized. This is particularly pertinent in the
primary care setting where the majority of delays in diagnosis are
thought to occur [1,3]. Certainly a positive or intermediate PPD test
would raise suspicion for a diagnosis of scrofula. In 1981, Olson
developed a methodology for diagnosing NTM lymphadenitis
based upon the variety of tests available [4] (Table 2). He outlined
four categories based on increasing degrees of suspicion for NTM as
the cause for the lesion. While category IV diagnostic criteria may
justify empirical treatment of NTM as the presumed cause of the
lymphadenopathy, a re-evaluation of the patient’s history and
exclusion of other causes of infection such as cat scratch disease
are still in order.
3.4. Treatment
Complete excision of the affected lymph node(s) has been
described as the definitive therapy for NTM lymphadenitis. As
such, it has been categorized as a ‘‘surgical disease’’. Schaad et al.
described a 92% cure rate among patients with NTM lymphadenitis
who underwent excision alone [13]. These cases included 82 at
Schaad’s institution, as well as 298 patients from a literature
review. Tunkel reported that 100% of patients treated by excision
alone were cured without requiring further surgical intervention
[7]. Rahal et al. described that one patient of fifty (2%) had
recurrence, requiring a second surgical procedure four months
after complete excision of the lesion failed to result in resolution
[8]. Panesar et al. described resolution of the infection in 54 of 55
patients, or a 98% cure rate after total excision of the affected node
[3]. In a multicenter, randomized, controlled trial, Lindeboom et al.
reported cure rates in 48 of 50 patients (96%) undergoing surgical
excision with no recurrences at six months. However, one patient
(2%) had recurrence and another (2%) developed a new submental
lesion, both of which were successfully treated with three months
of antimicrobials [14]. Finally, Wei et al. related resolution of
infection with no recurrence in 18 of 19 patients (95%) undergoing
complete excision; however, they also report that 56% of patients
undergoing a non-excisional procedure as first-line surgery
experienced recurrence or persistence of disease [12].
Several factors may hinder attempts at complete surgical
excision, making this treatment technique difficult. These include
secondary skin involvement resulting in dermal necrosis, adverse
cosmetic outcome, and proximity of the infected node to branches
1601
of the facial nerve. Intra-operative nerve stimulation is a helpful
technique to ensure protection of the facial nerve braches
underlying the mass [13]. Facial nerve monitoring is another
helpful technique which has been utilized in identification of the
underlying motor nerves. While total excision is thought to be
curative, it is not always feasible.
Multiple other treatments for NTM cervicofacial lymphade-
nopathy have been suggested [1,3–7,12–22]. The possible treat-
ments include: no intervention; antimicrobial therapy alone; FNA;
incision and drainage; incision and curettage; or complete excision
of the lesion with staged closure. Any of the aforementioned
treatments may be applied in conjunction with another and/or
with the administration of antimicrobial therapy.
Debulking is often employed where total excision proves
difficult. Incision and curettage is certainly one such option which
has sparked much debate. Olson reported 13 patients who
underwent incision and curettage, all of whom had no recurrence
in an average 23-month follow-up [4]. Kennedy similarly reported
7 patients who underwent incision and curettage, also with no
recurrence after a mean follow-up of nearly 16 months. Kennedy
goes on to suggest that curettage is best carried out when the
affected lymph node begins to show signs of fluctuation [5].
Tunkel, on the contrary, reported a recurrence rate of 55% in those
undergoing curettage; however, 50% of those with recurrence were
designated to undergo a second surgery as part of planned staged
procedures [7]. Panesar et al. likewise reported success with
debulking efforts for extensive involvement of the lesion [3].
Incision and drainage is generally believed to be an ineffective
therapy, as persistent, draining fistulae often result. This is in
contrast to the typical bacterial pyogenic abscess, whereby
drainage of the infectious material typically provides a curative
outcome. Suskind et al. reported that 9 out of 10 patients
undergoing incision and drainage procedures for NTM lymphade-
nitis ultimately required a second procedure [15]. Panesar et al.
described a persistent draining fistula necessitating a second
procedure in 20 of 21 patients who initially underwent incision
and drainage [3]. Schaad et al. reported a mere 16% cure rate after
incision and drainage in 63 patients, which was irrespective of
concurrent anti-tuberculous chemotherapy [13]. Scarring associ-
ated with incision and drainage has also been found to be a
problem. Mandell et al. found that in 5 of 14 patients undergoing
incision and drainage, a chronic, hypertrophic and erythematous
scar resulted [16]. However, scarring from incision and drainage
was not compared to scarring associated with complete excision.
Fine needle aspiration (FNA) of the lesion may serve both a
diagnostic and therapeutic function. FNA as a diagnostic tool is
well tolerated and supported. Therapeutic FNA has also been
reported as successful. Alessi and Dudley described therapeutic
aspiration in nine patients, with no reported recurrences. Notably,
four patients required more than one aspiration, and all nine were
on varied antimicrobial therapies prior to this treatment [17].
Parents should be educated regarding the possibility of persistent
drainage from the aspiration site and possible need for definitive
surgery when the technique is utilized in a therapeutic role [16].
As there are varied approaches to surgical treatment of NTM
cervicofacial lymphadenitis, Mandell et al. have suggested an
individualized approach to surgical treatment based on 4 tenets:
(1) potential for facial nerve injury; (2) cosmetic results; (3)
parental tolerance for protracted clinical course; and (4) status of
the lesion (skin loss, active drainage) [16]. The need for an
individualized approach to management suggests that this disease
is not uniform in its manifestations and should not be treated
unvaryingly.
Antimicrobial therapy directed against NTM has been shown to
be efficacious either alone or in conjunction with surgical
intervention [14,18–23]. Factors distinguishing NTM lymphadenitis
1602 R. Penn et al. / International Journal of Pediatric Otorhinolaryngology 75 (2011) 1599–1603

that will resolve with antimicrobial therapy alone from NTM

lymphadenitis that will require a surgical intervention remain
elusive. One study by Harris et al. has shown that deep neck NTM can
resolve with antibiotics; however there was limited sample size
[23]. Most reported successes have included treatment with
clarithromycin (7.5 mg/kg given twice daily), or clarithromycin
and rifabutin (5 mg/kg given once daily) [18–20]. Side effects of
rifabutin include neutropenia, dose-related uveitis and pseudo-
jaundice [21]. A recent retrospective study indicates resolution of
NTM lymphadenopathy with clarithromycin alone. Luong et al.
reported response (complete or partial resolution of skin changes
and palpable lymphadenopathy) with clarithromycin alone within
two months of treatment in 13 of 15 children [22]. It appears that a
minimum of 2 months of antimicrobial therapy is indicated in
treatment of NTM lymphadenitis [21]. Lindeboom et al. reported
cure in 33 of 50 patients (66%) with dual use of clarithromycin and
rifabutin [14]. However, this study considered treatment to have
failed with patient intolerance to antibiotic therapy, no improve-
ment at three months, and evidence of a draining fistula at 6-month
evaluation. An additional 11 patients (22%) were considered cured Fig. 2. Stage I of NTM cervicofacial lymphadenopathy.

after 6 months of therapy.

4. Discussion

Key features of NTM cervicofacial lymphadenitis lend them-

selves to a classification schema. First, and most importantly,
diagnostic efforts must be undertaken during the earliest phase of
NTM lymphadenitis to distinguish it from tuberculous scrofula,
which can infect individuals in contact with the patient. Olson’s
diagnostic categories help accomplish this distinction while
providing a gradation system for securing the diagnosis of NTM
lymphadenitis. Second, the classification of NTM cervicofacial
lymphadenitis can provide a universally accepted system, thereby
permitting earlier diagnosis and an improved treatment regimen. Fig. 3. Stage III of NTM cervicofacial lymphadenopathy.

We have identified four distinct clinical stages of NTM

infections of the head and neck. These clinical stages reflect the
inherent progression of the infectious process (Table 3). Stage I is
characterized by a firm, painless mass which may present with
notable increase in vascularity and erythema (Fig. 2). Stage II is
characterized by liquefaction of the affected lymph node, causing
the mass to be fluctuant by palpation. Significant skin changes
characterize Stage III, whereby overlying skin may develop
violaceous discoloration and become notably thinner, or parch-
ment-like, with a ‘‘shiny’’ appearance (Fig. 3). Finally, during Stage
IV, the lesion fistulizes to the skin surface causing a draining
wound.
Persistent cervicofacial lymphadenopathy in the pediatric
population should evoke a thorough differential diagnosis.
Recognizing the various stages of NTM lymphadenopathy may
aid primary care physicians in isolating a diagnosis in a timely
fashion. It may also prevent use of a treatment not otherwise
indicated or one that would better treat a different stage of the
infectious process. If the early stages of the infection (stages I
and II) are more readily recognized, we might expect less delay in
referral from the primary care setting in these instances.
The tenets suggested by Mandell et al. regarding an individual-
ized approach to treatment should be utilized in the decision-
making process [16]. However, specific therapeutic interventions
are more strongly indicated during certain stages of the infection
than in others. Treatment options specific to a given clinical stage
may be based on an individual approach (Table 4).
The incidence of Stage I NTM cervicofacial lymphadenitis that
spontaneously resolves is not yet known; as such, treatment is
indicated. Indeed, we recommend clarithromycin antibiotic
therapy at all clinical stages of the infectious process. This medical
intervention offers relatively minimal adverse effects and is
generally well tolerated. At present, there is no prospective study
Table 4
Treatments recommended at the various clinical stages.

Clinical stage Treatment

Stage I Antibiotics
Table 3
Georgetown staging system of nontuberculous mycobacterial cervicofacial Stage II Antibiotics
lymphadenitis [5]. FNA+/
Stage I Painless, firm Curettage +/ Staged Excision
Adherent to overlying skin Excision
Increased vascularity Stage III Antibiotics
Stage II Fluctuance FNA+/
Curettage +/ Staged Excision
Stage III Skin changes – violaceous coloration
Thinning of skin, parchment-like changes, shiny appearance Stage IV Antibiotics
Excision +/ Staged Wound Closure
Stage IV Fistulization
FNA: fine needle aspiration.
 R. Penn et al. / International Journal of Pediatric Otorhinolaryngology 75 (2011) 1599–1603
demonstrating the efficacy of a macrolide antibiotic as compared
to combination therapy with rifabutin. Consequently, the potential
benefit of combined antimicrobial therapy must be weighed
against the adverse effects of rifabutin.
Once the lesion has become fluctuant (Stage II), other treatment
modalities may be employed. FNA may provide both diagnostic
and therapeutic drainage of the liquefied debris. Nonetheless, the
risk of persistent drainage from the aspiration site must be noted as
a possible adverse outcome. Curettage is a viable method of
draining lymph node contents; however, it may require definitive
excision at a later point if complete resolution does not occur. As
with FNA, caregivers must be cautioned regarding persistence of a
draining wound and the possibility of scar formation. Excision may
also be attempted in Stage II if a distinct advantage exists over
curettage. While excision offers complete removal of the affected
node, surgical scar formation must be discussed prior to the
operation. By Stage III, skin changes are not amenable to total
excision and wound closure, leaving curettage as a better option
for surgical intervention. Finally, by Stage IV, the wound has
fistulized. Both the time frame, and likely, the effectiveness of
fistulization in clearing the infection are less than ideal. Cosmetic
outcome is likewise a concern. Therefore, excision with staged
closure is recommended.
5. Conclusion
Where routine antibiotics fail to improve chronic unilateral
lymphadenopathy in the pediatric population, NTM lymphadenitis
should be considered. A universally accepted classification system
of the NTM lymphadenitis clinical stages would provide better
characterization of the process. Furthermore, NTM lymphadenitis
may be included in the differential diagnosis earlier in the patient
evaluation and work-up, namely, in the primary care setting. The
diagnostic process must eliminate Mycobacteria tuberculosis as a
cause for the lymphadenitis. Needle aspiration, specific NTM
antigen testing, PCR or excision of the mass may confirm the
presumed diagnosis. CT scanning may show characteristic signs
consistent with NTM lymphadenitis and may be of further benefit
if needed for surgical planning. The NTM classification system
provides for appropriate therapeutic interventions for a given
clinical stage. Macrolide antibiotics should be utilized in all stages
of the infectious process. Other stage-specific treatment options
may then be chosen based on an individual approach.
References
[1] E.H. Harley, Atypical tuberculosis (nontuberculous mycobacterium) of the parotid
region in children, Otolaryngol. Head Neck Surg. 119 (September (3)) (1998) 294.
1603
[2] E.G. Chadwick, E.A. Rosenfeld, Mycobacterium species non-tuberculosis, in: S.S.
Long, L.K. Pickering, C.G. Prober (Eds.), Principles and Practice of Pediatric Infec-
tious Diseases, 2nd ed., Elsevier Science, Philadelphia, PA, 2003, pp. 811–815.
[3] J. Panesar, K. Higgins, H. Daya, V. Forte, U. Allen, Nontuberculous mycobacterial
cervical adenitis: a ten-year retrospective review, Laryngoscope 113 (2003)
149–154.
[4] N.R. Olson, Nontuberculous mycobacterial infections of the face and neck—
practical considerations, Laryngoscope 91 (1981) 1714–1726.
[5] T.L. Kennedy, Curettage of nontuberculous mycobacterial cervical lymphadenitis,
Arch. Otolaryngol. Head Neck Surg. 118 (1992) 759–762.
[6] M.J. Evans, N.M. Smith, C.M. Thornton, G.G. Youngson, E.S. Gray, Atypical myco-
bacterial lymphadenitis in childhood—a clinicopathological study of 17 cases, J.
Clin. Pathol. 51 (1998) 925–927.
[7] D.E. Tunkel, Surgery for cervicofacial nontuberculous mycobacterial adenitis in
children: an update, Arch. Otolaryngol. Head Neck Surg. 125 (1999) 1109–1113.
[8] A. Rahal, A. Abela, P.H. Arcand, M. Quintal, M.H. Lebel, B.F. Tapiero, Nontubercu-
lous mycobacterial adenitis of the head and neck in children: experience from a
tertiary care pediatric center, Laryngoscope 111 (2001) 1791–1797.
[9] S. Bagla, D. Tunkel, M. Kraut, Nontuberculous mycobacterial lymphadenitis of the
head and neck: radiologic observations and clinical context, Pediatr. Radiol. 33
(2003) 402–406.
[10] R. Hazra, C.D. Robson, A.R. Perez-Atayde, R.N. Husson, Lymphadenitis due to
nontuberculous mycobacteria in children: presentation and response to therapy,
Clin. Infect. Dis. 28 (1999) 123–129.
[11] C.D. Robson, R. Hazra, P.D. Barnes, R.L. Robertson, D. Jones, R.N. Husson, Non-
tuberculous mycobacterial infection of the head and neck in immunocompetent
children: CT and MR findings, Am. J. Neuroradiol. 20 (1999) 1829–1835.
[12] J.L. Wei, J. Bond, K.J. Sykes, R. Selvarangan, M.A. Jackson, Treatment outcomes for
nontuberculous mycobacterial cervicofacial lymphadenitis in children based on
the type of surgical intervention, Otolaryngol. Head Neck Surg. 138 (2008)
566–571.
[13] U.B. Schaad, T.P. Votteler, G.H. McCracken, J.D. Nelson, Management of atypical
mycobacterial lymphadenitis in childhood: a review based on 380 cases, J.
Pediatr. 95 (1979) 356–360.
[14] J.A. Lindeboom, E.J. Kuijper, E.S. Bruijnesteijn van Coppenraet, R. Lindeboom, J.M.
Prins, Surgical excision versus antibiotic treatment for nontuberculous mycobac-
terial cervicofacial lymphadenitis in children: a multicenter, randomized, con-
trolled trial, Clin. Infect. Dis. 44 (2007) 1057–1064.
[15] D.L. Suskind, S.D. Handler, L.W.C. Tom, W.P. Potsic, R.F. Wetmore, Nontuberculous
mycobacterial cervical adenitis, Clin. Pediatr. 36 (1997) 403–409.
[16] D.L. Mandell, E.R. Wald, M.G. Michaels, J.E. Dohard, Management of nontubercu-
lous mycobacterial cervical lymphadenitis, Arch. Otolaryngol. Head Neck Surg.
129 (2003) 341–344.
[17] D.P. Alessi, J.P. Dudley, Atypical mycobacteria-induced cervical adenitis: treat-
ment by needle aspiration, Arch. Otolaryngol. Head Neck Surg. 114 (1988)
664–666.
[18] C. Berger, G.E. Pfyffer, D. Nadal, Treatment of nontuberculous mycobacterial
lymphadenitis with clarithromycin plus rifabutin, J. Pediatr. 128 (1996) 383–386.
[19] M.B. Shah, J. Haddad, Nontuberculous mycobacteria-induced parotid lymphade-
nitis successfully limited with clarithromycin and rifabutin, Laryngoscope 114
(2004) 1435–1437.
[20] M. Tessier, J. Amoric, F. Mechinaud, D. Dubesset, P. Litoux, J. Stalder, Clarithro-
mycin for atypical mycobacterial lymphadenitis in non-immunocompromised
children, Lancet 334 (1994) 1778.
[21] A.M. Loeffler, Treatment options for nontuberculous mycobacterial adenitis in
children, Pediatr. Infect. Dis. J. 23 (2004) 957–958.
[22] A. Luong, J.E. McClay, H.S. Jafri, O. Brown, Antimicrobial therapy for nontubercu-
lous mycobacterial cervicofacial lymphadenitis, Laryngoscope 115 (2005)
1746–1751.
[23] R.L. Harris, P. Modayil, J. Adam, M. Sharland, P. Heath, T. Planche, et al., Cervi-
cofacial nontuberculous mycobacterium lymphadenitis in children: is surgery
always necessary? Int. J. Pediatr. Otorhinolaryngol. 73 (September (9)) (2009)
1297–1301 (Epub 2009 July 7).