Rethinking NTM lymphadenitis: Observation emerges as a safe first-line strategy
Cervicofacial nontuberculous mycobacterial (NTM) lymphadenitis is a self-limiting condition that presents as a persistent neck mass in young children. It typically does not respond to antibiotics, so surgical excision has long been considered curative.
In a recent study, experts at Children’s HealthSM demonstrate how observation alone can be safe and effective for most patients. Contributors include:
Christopher Liu, M.D., Otolaryngologist at Children’s Health and Associate Professor of Pediatric Otolaryngology at UT Southwestern
Amanda Evans, M.D., Infectious Disease Specialist at Children’s Health and Associate Professor of Pediatric Infectious Disease at UT Southwestern
Stephen Chorney, M.D., Otolaryngologist at Children’s Health and Associate Professor of Pediatric Otolaryngology at UT Southwestern
Observation shifts the approach for these cases – not by eliminating surgery, but by introducing a viable path where intervention may not be necessary.
Observation alone resolves most pediatric NTM lymphadenitis cases
Despite prior studies, consensus on optimal management of cervicofacial NTM lymphadenitis remains limited. In the absence of widely accepted practice guidelines, clinicians often rely on personal experience, favoring the method they know best, whether surgical excision or medical therapy.
Both options have limitations:
Antibiotic therapy is often prolonged, involves multiple agents and does not reliably resolve the lesion.
Surgical excision carries a risk of injury to the marginal mandibular nerve, with potential for lower lip weakness or asymmetry.
COVID-related OR closures provided an unplanned case study of the effects of postponing surgery. When operating rooms shut down during the pandemic, even patients who were clear surgical candidates had no choice but to wait. Months later, when ORs reopened, families who were contacted to reschedule consistently reported that their child’s lesion had already resolved.
“When we saw how many of these cases resolved without intervention, we started to wonder whether surgery is necessary, given the risk,” says Dr. Liu.
Study findings and implications for clinical management
To better understand outcomes associated with observation in cervicofacial NTM lymphadenitis, the team conducted a retrospective review of patients treated at Children’s Health.
Study design and outcomes
Retrospective study of 72 pediatric patients (2017–2023)
63% managed with observation-only; 37% underwent surgical excision
Among observed patients, median time to resolution was 123 days (~5.5 months)
82.8% of observed cases resolved by 12 months
Minimal morbidity in the observation group; one case required scar revision
In the surgical group, 11% experienced marginal mandibular nerve weakness
“What our study shows is that we can step back and consider a path that reflects how the disease typically progresses,” says Dr. Liu. “It can take time, but observation is a safe and appropriate starting point for most children.”
Surgical excision remains appropriate in select cases. Lesions located away from the marginal mandibular nerve may be more amenable to excision, particularly when identified before overlying skin becomes violaceous.
Clinical evaluation and management of NTM lymphadenitis
Children’s Health sees 30 to 40 NTM lymphadenitis cases per year – among the highest case volumes in the region. That depth of experience shapes every step of care and allows the team to offer every option.
Because the condition can look concerning – a persistent neck mass in a young child, sometimes with violaceous overlying skin – accurate diagnosis is a critical first step. “A big part of our role is making sure this isn’t something else, like tuberculosis,” says Dr. Evans. Infectious disease and otolaryngology work together from the outset, bringing complementary expertise to confirm the diagnosis and identify the right management path for each patient.
Who is a good candidate and how to learn more
For families whose children are candidates for observation, data-informed counseling anchors expectations to defined timelines to provide a clear picture of how NTM lymphadenitis typically progresses. Excision is reserved for earlier-stage lesions and those with favorable location relative to the marginal mandibular nerve. And for families with cosmetic concerns, surgeons perform revision procedures using superficial techniques that avoid dissection near the marginal mandibular nerve.
“Because of our experience managing these cases, we’re able to guide families through both observation and surgical options in a thoughtful way,” says Dr. Liu. “That allows us to tailor the approach based on how the disease presents and progresses in each child.”
Learn more about pediatric otolaryngology and infectious diseases programs at Children’s Health.
