World J. Surg. 21, 516 –519, 1997 WORLD Journal of SURGERY © 1997 by the Socie ´te ´ Internationale de Chirurgie Management of Mycobacterial Cervical Lymphadenitis Muzaffer Kanlikama, M.D., 1 Avni Go ¨kalp, M.D. 2 1 Department of ENT Surgery, University of Gaziantep, Faculty of Medicine, Kolejtepe, 27070 Gaziantep, Turkey 2 Department of General Surgery, University of Gaziantep, Faculty of Medicine, Kolejtepe, 27070 Gaziantep, Turkey Abstract. The treatment results of mycobacterial cervical lymphadenitis in 69 patients between 1990 and 1993 are reviewed. All patients underwent surgical procedures consisting of total excision or selective nodal dissec- tion for lymphadenopathies and curettage for fluctuant cases, followed by antituberculous chemotherapy applied according to the likely or proved mycobacterial species. For this purpose, three or four drugs (including isoniazid, rifampin, ethambutol, and streptomycin) were used for 12 to 18 months. The cure rate was 100% after a minimum follow-up of 3 years. Clinical features, treatment modes, and guidelines for management are discussed. Peripheral mycobacterial lymph node disease is the most common form of extrapulmonary mycobacterial disease, and mycobacterial lymphadenitis most frequently affects the cervical region [1]. This finding agrees with the fact that the head and neck region contains approximately 30% of all lymph nodes in the body [2]. Since the turn of the century it has been known that mycobac- terial cervical lymphadenitis (MCL) is caused only by human tuberculosis, whereas other forms of mycobacteria are widely distributed as saprophytic organisms in nature such as soil and water. For a long time these other forms of mycobacteria were regarded as nonpathogenic in humans. After the introduction of effective antituberculous chemotherapy (ATC), it became increas- ingly apparent that forms of mycobacteria other than tuberculosis cause human disease. These organisms have been termed anon- ymous, atypical, or nontuberculous mycobacteria (NTM) [3–5]. The first descriptions of cervical lymphadenitis (CL) due to NTM was reported in 1956 by Prissick and Masson [6]. Since then, many reports have been published about NTM-CL. Tuberculosis has been continued to be a public health problem around the world. After a long period of decline, the rate of infections due to Mycobacterium tuberculosis and atypical myco- bacteria has increased during the past decade [7]. This infection appeared to be more probable within the acquired immunodefi- ciency syndrome (AIDS) patients, and the recent increase of AIDS cases appears to be accompanied by an increase in the prevalence of mycobacterial disease, especially NTM infection. Mycobacterial disease together with human immunodeficiency virus (HIV) infection has been called the “cruel duet.” Despite the presently effective chemotherapy against human tuberculosis, an increase rate of NTM infections have been observed owing to the advances in cultural techniques, differential tests, and skin tests [8 –11]. Publications from developed countries show that the most frequent agents isolated from MCL are NTM [3, 10 –13]. On the other hand, in underdeveloped or developing countries, lymphadenopathy associated with tuberculosis has maintained its frequency [14, 15]. The clinical and laboratory distinction between tuberculous cervical lymphadenitis (TCL) and NTM-CL is very important for the management of MCL. Because TCL is a local manifestation of the systemic disease, ATC is considered to be the main treatment. In contrast, NTM-CL is considered to be a localized disease that requires surgical excision. In this article, the results of the management of MCL patients are presented and discussed. Also, some implications about the management of MCL are emphasized. Materials and Methods We retrospectively reviewed 69 patients diagnosed as having MCL by histologic examination from April 1990 to March 1993. There was a minimum follow-up of 3 years. A detailed history was obtained for the patients referred to our clinics with neck masses or draining sinuses. The history included the presence of previous tuberculous infection, tuberculous contact, and constitutional symptoms such as fever, fatigue, and weight loss. Also, a careful physical examination was undertaken along with laboratory and radiologic investigations, including a complete blood count (CBC), urinalysis, erythrocyte sedimentation rate (ESR), Brucella and Toxoplasma assays, cervical and chest radiographs. A stan- dard or typical purified protein derivative (PPD) test (PPD-S or PPD-T) was applied. PPD for NTM (antigens of PPD-B or PPD-NTM) was not done because it was unavailable. After these tests, an excisional biopsy or selective nodal dissec- tion was performed, especially in children or patients who did not have systemic upset, tuberculous contact, or a tuberculous history and in patients with unilateral and single-site foci and with preauricular and submandibular or its neighboring locations. These procedures were also performed in patients with a normal chest radiograph and negative or weak PPD results. Curettage was preferred when skin necrosis or fluctuation was present or for Correspondence to: M. Kanlikama, M.D.