Complete Surgical Excision of Cervicofacial Nontuberculous Mycobacterial Lymphadenitis in Children

Background: Nontuberculous mycobacterial (NTM) cervical lymphadenitis is an uncommon but clinically challenging pediatric condition that often mimics other causes of neck masses and is therefore frequently misdiagnosed or mistreated. This study aimed to describe the diagnostic work-up, surgical management, complications, and outcomes of complete surgical excision in children with cervicofacial necrotizing granulomatous lymphadenitis consistent with NTM disease. Methods: We retrospectively analyzed 70 children (48 girls and 22 boys; mean age, 4 years) who underwent surgery between 2010 and 2023. Clinical presentation, diagnostic work-up, microbiological findings, extent of surgery, follow-up, and outcomes were reviewed. Results: Most children presented with advanced disease, including fistulization in 32/70 (46%) and subcutaneous infiltration in 23/70 (33%). The median interval between first observation and surgery was 12 weeks (IQR, 9–21). NTM was microbiologically confirmed in 58 children; the remaining 12 were classified as presumptive NTM cases on the basis of typical clinical–anatomic features, necrotizing granulomatous histopathology, and exclusion of alternative causes. Interferon-gamma release assay was negative in all 39 tested children, whereas purified protein derivative skin testing was positive in 7/34 (21%). Among the 64 children who underwent the full institutional microbiological work-up, the overall diagnostic yield reached 58/64 (91%), and Mycobacterium avium was the predominant isolate. Surgical treatment ranged from single-level excision to multilevel dissection and/or parotidectomy. Postoperative lower-lip asymmetry occurred in 27/51 (53%) children undergoing parotid or level I surgery and persisted beyond 3 months in 7; four of these seven recovered by 12 months, while three had barely perceptible dynamic asymmetry at their last clinical assessment. Clinical follow-up lasted 2 years; the interval to final telephone contact about subsequent lymphadenopathy ranged from 2 to 16 years (mean, 8 years). No recurrence at the operated site was reported, and one metachronous parotid lesion was successfully treated. Conclusions: Pediatric NTM cervical lymphadenitis often presents late, with advanced local disease. In this selected surgical cohort, complete surgical excision provided excellent long-term local control, although postoperative lower-lip asymmetry was common after surgery close to the marginal mandibular branch, and minimal residual asymmetry was observed in three patients. Early recognition, microbiological confirmation when feasible, and referral to experienced centers are essential for optimal management.