FLEX February 2024

C.F. Roy et al.

International Journal of Pediatric Otorhinolaryngology 166 (2023) 111469

Methods: A modified three-iterative Delphi method was used to establish expert recommendations on the diag nostic considerations, expectant or medical management, and operative considerations. The recommendations herein are derived from current expert consensus and critical review of the literature. Setting: Multinational, multi-institutional, tertiary pediatric hospitals. Results: Consensus recommendations include diagnostic work-up, goals of treatment and management options including surgery, prolonged antibiotic therapy and observation. Conclusion: The recommendations formulated in this International Pediatric Otolaryngology Group (IPOG) consensus statement on the diagnosis and management of patients with NTM lymphadenitis are aimed at improving patient care and promoting future hypothesis generation.

1. Consensus objectives To provide recommendations on diagnostic and management con siderations for patient presenting with suspected non-tuberculous mycobacterial (NTM) cervicofacial lymphadenitis. 2. Target population Pediatric patients with suspected NTM cervicofacial lymphadenitis. 3. Intended users These consensus recommendations are intended to provide comprehensive care recommendations for primary care providers, pe diatricians, infectious disease specialists and otolaryngologists who manage patients with NTM cervicofacial lymphadenitis. The content herein was derived from a critical review of the literature, and expert recommendations from pediatric otolaryngologists. We recognize phy sicians specializing in pediatrics and infectious diseases may further contribute to the management of these patients and encourage multi disciplinary collaboration when treating pediatric patients with sus pected NTM cervicofacial lymphadenitis. 4. Methods The mission of the IPOG is to develop expertise-based consensus recommendations for the management of pediatric otolaryngologic disorders with the goal of improving patient care. A three-iterative modified Delphi method was used to establish expert recommenda tions on the diagnostic considerations, goals of therapy and initial management options (including surgical and non-surgical manage ment), and follow-up. An online survey was designed by authors C.R., J. Y. and R.R. and distributed to the members of the IPOG. Responses were subsequently collated, anonymized and redistributed in two subsequent surveys. Respondents were given the opportunity to comment on the format and content of the survey and revise their responses accordingly. The recommendations herein are derived from a critical review of the literature and expert opinion of 30 members of the International Pediatric Otolaryngology Group (IPOG), representing 26 tertiary care pediatric hospitals across ten countries. Consensus was defined as > 80% agreement amongst survey respondents. The degree of consensus was quantified by presenting the percentage of above authors who agree or partially agree with each statement where significant variability was noted. Pediatric otolaryngologists included in this consensus statement were asked to inquire with their local pediatrics and infectious disease specialists with regards to questions pertaining to the non-operative management of NTM lymphadenitis. 5. Disclaimer This report was prepared by members of the IPOG and consensus recommendations are based solely on the collective expert opinion of the members of this group. IPOG members are asked to provide intel lectual contribution to areas within their field of expertise, with no

financial compensation. When applicable, relevant peer-reviewed liter ature supporting these recommendations is cited. Any person seeking to apply the recommendations herein is expected to apply independent medical judgement to individual patients, institutional resources, local epidemiology and specific circumstances. The recommendations herein do not apply to immunocompromised patients. 6. Recommendations and justification The recommendations are outlined in the following sections. • Section 1: Diagnostic considerations o1.1 Definitions o1.2 Laboratory investigations o1.3 Microbiology and virology o1.4 Radiology o1.5 Fine-needle aspiration • Section 2: Initial management o2.1 Goals of treatment o2.2 Initial management options and modifying factors NTM cervicofacial lymphadenitis will classically present as a pain less, subacute or chronic lymphadenopathy in children under five years of age [1,2]. It most commonly involves submandibular, cervical and parotid lymph nodes [3]. As the affected nodes enlarge, the overlying skin characteristically becomes thinner and may gradually change from a pink to violaceous hue. Suppuration through a sinus tract may occur. Most immunocompetent children will have no systemic infectious symptoms beyond the local site [4]. The diagnosis of definite NTM lymphadenitis is established based on a positive mycobacterial culture and/or polymerase chain reaction test of the purulent discharge or aspirate. Alternatively, a diagnosis of probable NTM lymphadenitis may be established solely based on a characteristic clinical presentation (including history, physical exami nation and concordant investigations). Diagnostic uncertainty may be challenging particularly in the early stages of disease, and additional supportive investigations may narrow the differential diagnosis. Variation in practice among the current group members remains with regards to specific laboratory, microbiology and radiological investigations routinely or selectively ordered. The following sections aim to provide a list of reasonable options based on expert opinion and provide a rationale for their use. A proposed diag nostic algorithm is presented in Fig. 1, while Table 1 provides response rates to associated survey items. 6.1.2. Laboratory investigations A complete blood count with differential may be ordered, which is • Section 3: Operative considerations • Section 4: Non-surgical management • Section 5: Follow-up 6.1. Section 1: Diagnostic considerations 6.1.1. Definition and diagnosis

2

Downloaded for Anonymous User (n/a) at Seattle Children's Hospital from ClinicalKey.com by Elsevier on December 18, 2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved.