An otherwise healthy three-year old girl presents to your clinic with a tender, erythematous lower left neck mass that has developed over the past six weeks. She has been treated with clarithromycin and rifampin for two weeks with no improvement.

 

 

[size=20px]our recommended management of this neck mass is

 

A curettage.

 

B continued antibiotics.

 

C fine needle aspiration biopsy.

 

D incisional biopsy.

 

E complete excision.[/size]

looks like fourth branchial cleft cyst. E. complete excision

correct answer

 

E complete excision.

 

Nontuberculous or atypical mycobacterial lymphadenitis in children often presents as a neck mass with red/purple, thin, flaky overlying skin. The most common location is submandibular, although preauricular and other neck sites are other possible locations. It typically occurs in children 1-5 years of age and is rare in immunocompetent children older than 12 years. The most common organisms are Mycobacterium avium (70%) or hemophilum (20%). Preoperative diagnosis is clinical and laboratory tests are nonspecific. Signs, symptoms, and laboratory tests typically show remarkably little evidence of systemic inflammation. Diagnosis is confirmed by finding acid fast organisms on tissue specimens.

 

The best outcome is from complete surgical excision. Complications after surgical excision are not uncommon and include wound infections and marginal mandibular nerve injury. When excision is incomplete then persistent or recurrent lymphadenopathy and chronic wound sinuses are often seen.

 

If the inflammatory mass is large or in a location where complete excision would have a significant risk of injury to adjacent nerves or other structures then there may be a role for drainage, debulking or curettage although a prolonged (weeks to months) time to resolution is typical. In the case presented, complete surgical excision is feasible and is the best treatment option. Curettage would probably result in a wound that would not heal for months, and incisional or fine needle aspiration biopsy could confirm the diagnosis but are not necessary and would have a high risk of a chronic wound sinus.

 

The natural history of nontuberculous mycobacterial lymphadenitis is that it often resolves without treatment, although that typically would take 6 to 12 months and there can be significant skin and soft tissue scarring. Whether or not the antibiotics (clarithromycin and rifampin are the most commonly used) can hasten resolution of the lymphadenitis or improve surgical outcomes is unclear.