FLEX February 2024

C.F. Roy et al.

International Journal of Pediatric Otorhinolaryngology 166 (2023) 111469

of NTM lymphadenitis. This is largely based on Zimmerman et al.‘s meta-analysis, which reported no cure rate benefit to anti-mycobacterial therapy when compared to observation [3]. Antibiotics may, however, reduce the risk of fistula formation when compared to observation alone, and are thus commonly prescribed in multiple institutions [7,21]. If antibiotics are offered, physicians should obtain a baseline com plete blood count. Of note, although not reaching the pre-established consensus threshold, some IPOG members suggest obtaining the following investigations prior to antibiotic initiation and repeating during therapy to objectively assess for development of any treatment related side effects: hepatic function tests (61%), electrocardiogram (17%), audiogram (17%), renal function tests (4%) and visual acuity testing (4%). IPOG respondents reported high variability amongst institutions and practitioners in both the antibiotic regimen and duration. Some offer single-agent therapy with a macrolide, while others add one or two other anti-mycobacterial agents (commonly rifampin with or without ethambutol). While this variability was reported in the context of cer vicofacial adenopathy, there is compelling evidence outside of otolar yngology indicating a strong propensity towards drug resistance in the mycobacterium genus, and thus multidrug regimen is recommended [22,23]. With respect to duration of therapy, the majority of IPOG members agreed that antibiotics, if given, should be administered for at least 3 months. Patients should be reassessed clinically at least at monthly intervals, and appropriate monitoring for drug related side effects. Adverse events commonly observed with anti-tuberculin regimens include transient tooth discoloration, fever, and gastrointestinal disturbances [3,24,25]. Moderate to severe side effects are rare but may include: QT interval prolongation (macrolide antibiotics), ototoxicity and nephrotoxicity (amikacin and streptomycin), hepatotoxicity (isoniazid), optic neurop athy (ethambutol), and cytopenias [3,8]. What constitutes failure of antibiotic therapy is poorly defined in the literature. The group reached consensus on the following: development of moderate to severe drug-related adverse events or poor treatment tolerance, progression of skin changes or sinus tract formation and progression in size of the lymphadenopathy or nodal conglomerate. Lack of improvement after prolonged antibiotic therapy was also suggested, albeit what constitutes an appropriate medical therapy trial varied across practitioners (54% felt 3 months was an adequate trial, while 38% and 8% suggested 6 and 12 months, respectively). Evidence of suppu ration on physical examination or imaging was supported by two thirds of members but did not reach the pre-defined consensus threshold. 6.4.1. Section 4: Follow-up Patients with NTM lymphadenitis should be followed clinically until resolution is achieved, regardless of the treatment modality sought. Scarring and fistula formation, if present, may be addressed once the acute infection is resolved according to patient and parental preference. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declaration of competing interest None. Acknowledgements Drs. Jeffrey Yeung (senior author) and Catherine Roy (first author) were the lead authors. All remaining authors are listed in alphabetical order. We are immensely grateful to Dr. Reza Rahbar for providing primary consulting and guidance regarding the design of the consensus recommendations. The authorship list follows the agreement of the

members of the IPOG. All authors have contributed to the conception and design of the work, drafting and critical revisions of the consensus recommendations. All authors approved the final version of this manuscript and are in agreement to be accountable for all aspects of the work. References [1] R. Penn, M.K. Steehler, A. Sokohl, E.H. Harley, Nontuberculous mycobacterial cervicofacial lymphadenitis - a review and proposed classification system, Int. J. Pediatr. Otolaryngol. 75 (12) (Dec 2011) 1599 – 1603, https://doi.org/10.1016/j. ijporl.2011.09.018. [2] G. Spinelli, G. Mannelli, F. Arcuri, E. Venturini, E. Chiappini, L. Galli, Surgical treatment for chronic cervical lymphadenitis in children - experience from a tertiary care paediatric centre on non-tuberculous mycobacterial infections, Int. J. Pediatr. Otolaryngol. 108 (May 2018) 137 – 142, https://doi.org/10.1016/j. ijporl.2018.02.042. [3] P. Zimmermann, M. Tebruegge, N. Curtis, N. 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