FLEX February 2024

C.F. Roy et al.

International Journal of Pediatric Otorhinolaryngology 166 (2023) 111469

Despite positive outcomes for most patients, consensus could not be reached on a single best treatment modality amongst IPOG members. The IPOG thus elected to first define goals of therapy, recognizing that there are patient, disease, physician and institution-specific factors that may influence the treatment algorithm. Five main goals of therapy were agreed upon and are presented in Fig. 2 in order of priority. Notably, in the setting of a benign and self-limited disease, the minimization of treatment-related morbidity must be emphasized. NTM lymphadenitis is ultimately a challenging condition to diagnose and treat, and centering patient/parental discussions around these ob jectives may help guide shared decision making. Diagnostic certainty, location/extent of the disease, surgeon experience and parental prefer ence are important considerations in establishing a treatment plan. 6.3. Section 3: Operative considerations A proposed algorithm for operative management of NTM lymphad enitis is presented in Fig. 3. If operative management is sought, complete excision is the preferred surgical approach if there is low risk to the facial nerve. Alternatively, incision and curettage may be considered, although associated with a lower reported cure rate in the largest meta- analysis (87.9%, C.I. 70.3 – 96.7) [3]. Intra-operative facial nerve moni toring is recommended when the affected node is near one of the branches of the facial nerve. Although not reaching the pre-defined consensus threshold, a ma jority of IPOG members routinely prescribe post-operative antibiotics (59%). The remaining members either do not prescribe antibiotics (19%) or do so only in cases of incomplete excision (22%). High practice variability exists with regards to the optimal regimen and duration, as depicted in Fig. 4.

Fig. 2. Goals of treatment.

compared to 73.1 and 70.4% for anti-mycobacterial antibiotics and observation, respectively [3]. Additional benefits to operative manage ment included a faster time to resolution, histopathologic and/or culture confirmation of the diagnosis and a decreased likelihood of a missed alternative diagnosis such as tuberculosis or malignancy. However, complete excision was also associated with the highest risk of compli cation, including facial nerve palsy [3]. In contrast, some institutions strongly favour non-operative man agement, stating operative risk including the potential for facial nerve injury must be carefully considered in the face of a benign and self- resolving disease in most affected patients [20]. Indeed, in the afore mentioned systematic review and meta-analysis, complete excision was associated with a 10% risk of facial nerve injury (2% permanent) [3]. In studies of patients treated expectantly, complete disease resolution was achieved in most patients, often after the formation of a sinus tract which may drain for 3 – 8 weeks before clearing with subsequent scarring [4,7].

Fig. 3. Surgical management.

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