Contemporary challenges in the diagnosis and treatment of nontuberculous mycobacterial cervicofacial lymphadenitis

Nontuberculous mycobacterial cervicofacial lymphadenitis is a rare infection in otherwise healthy young children, often presenting with an indolent course and fistula formation. This thesis explored diagnostic strategies, possible portals of entry, surgical challenges, and long-term treatment outcomes, aiming to improve early recognition, pathophysiological understanding, and prediction of treatment success.
Part 1 focused on diagnostics. A systematic review showed that a stepwise diagnostic approach is required to achieve sufficient sensitivity. Definitive diagnosis requires mycobacterial isolation via culture or polymerase chain reaction, while accurate, noninvasive tests remain unavailable. A cross-sectional study evaluated enzyme immunoassay targeting anti-glycopeptidolipid-core IgA antibodies demonstrated poor diagnostic performance (area under the curve = 0.55). Oral and oropharyngeal swabs also proved unsuitable as minimally invasive alternatives. Although portals of entry are hypothesized in the oropharynx, conjunctivae, or oral mucosa, this remains unproven.
Part 2 addressed treatment. A retrospective study showed that higher age and fistulization are associated with incomplete surgical excision, while lymph node size did not. A large case series with ≥10 years follow-up found excellent outcomes after surgical excision (98.7% success), compared to lower success with curettage (66%). A cohort study demonstrated superior long-term esthetic outcomes with primary surgery over non-surgical management or delayed surgery after failed conservative treatment.
When the findings of Part 1 and Part 2 are combined, it becomes clear that early recognition of the disease is difficult, but crucial for performing surgery at an early disease stage, enabling complete surgical removal of the infected tissue, minimizing complication rates and optimizing the esthetic outcome.