More on Atypical Mycobacteris in ORLHNS- Outline of Talk by our Registrar

Non-tuberculous mycobacteria (NTM) have become an increasingly important disease of childhood.

59 — 92% of mycobacterial cervicofacial infections in children are a result of NTM. Mainly affects

children <5 years, with most occurring 16 — 36 months of age. The great majority of children with

NTM are not immunologically impaired. The specific organisms are M. avium—intracellulare (aka

MAC, 70% to 90% of cases), M. kansasii, M. scrofulaceum, M. fortuitum, M. haemophilum, M.

abscessus, M. malmoense. Infection by M. bovis has decreased dramatically with the institution of

milk pasteurization.

These organisms are commonly found in soil, water, dust, aerosols, domestic and wild animals, milk,

and other food items. The portal of entry is believed to be through the mouth, and the tonsils have

been implicated in particular. The predilection for younger children is probably related to their

tendency to put contaminated objects in their mouths. The tendency to present in the winter

months may reflect the greater likelihood of viral upper respiratory infection in this season, which

might allow the causal organism easier access via inflamed mucous membranes. When within the

macrophage, MAC is able to survive within a vacuole and may ultimately use the macrophage as a

launching pad for infection if the host’s defences weaken.

The typical clinical presentation is of a painless, firm, enlarging and persistent neck mass that has

failed to respond to antibiotic therapy in a paediatric patient. The most common site of

mycobacterial infection in the neck is the anterior superior cervical region, followed by the posterior

cervical, middle cervical, supraclavicular, and submental regions. Atypical mycobacterial infection is

not infrequently found in the pre-auricular region. It tends to occur unilaterally. The skin becomes

adherent to the surrounding tissues and develops a characteristic violaceous discoloration. The

infection might progress to fluctuation and the development of a draining sinus. These lesions

generally produce few systemic symptoms. The differential diagnosis should include all diseases

specific to the salivary glands, tuberculous adenitis, infectious mononucleosis, cat-scratch disease,

brucellosis, actinomycosis, nocardiosis, toxoplasmosis, malignancies (especially lymphoma), and

macrocystic lymphatic malformation.

In addition cervical lymphadenitis, NTM may be involved with chronic otitis media (M. avium, M.

fortuitum, M. abscessus), or chronic laryngitis (M. leprae).

FNA carries the risk of fistula formation as does abscess incision and drainage. Mycobacterial

infection is definitively diagnosed by culture. Cultures for atypical mycobacteria may, however, be

negative even when infection is present. Only about 50% of excised diseased lymph nodes will be

culture positive. With a mean time of about eight weeks for culture and twelve weeks for sensitivity

results, initial diagnosis depends greatly on the clinical features. Most atypical mycobacteria elicit

granulomatous inflammation with acid-fast bacilli, and many establish cavitary disease difficult to

distinguish from TB. The histologic findings associated with MAC vary considerably and range from

granulomas to nodular foam cell lesions to purulent and necrotizing inflammations. Mantoux tests

for atypical mycobacteria are available and were at least weakly positive in 95% of cases in the series

by Hawkins and colleagues. NTM-specific antigens have been developed and are reported to be

extremely successful for diagnosis. Newer methods that use polymerase chain reaction techniques

to detect mycobacterial RNA in tissue and M. avium deoxyribonucleic acid in gastric aspirates are

still not widely available. 

Chest x-ray findings are typically absent. Contrast-enhanced CT images show asymmetric cervical lymphadenopathy with contiguous low-density, necrotic, ring-enhancing masses involving the subcutaneous fat and skin. In addition, inflammatory stranding of the subcutaneous fat characteristic of bacterial inflammation is minimal or absent with NTM infection.

The treatment of choice is complete surgical excision of the involved nodes. Medical treatment of

NTM with prolonged courses of antimicrobials is not well established. Hawkins and colleagues

showed resolution of neck masses in 4 of 18 cases of atypical mycobacterial infection with

chemotherapy alone. If excision is incomplete or disease recurs, fluoro-quinolones (e.g.

ciprofloxacin), clarithromycin or azithromycin plus ethambutol with rifampin should be used. If the

parotid gland is affected, a superficial parotidectomy with facial nerve preservation is necessary.

Removal of involved skin is often necessary during excision. Careful attention should be paid to

avoid any injury to the mandibular branch of the facial nerve because it is often adherent to the

tract. Patients with otitis media caused by M abscessus should receive clarithromycin plus an initial

course of amikacin plus cefoxitin. Surgical debridement may be required.

Mycobacterial Infections, Atypical Tuberculosis in Children

Definition

Atypical mycobacterial infections are infections caused by several types of mycobacteria.  It is quite common in Northland children. These atypical mycobacterial infections may also occur as a complication in patients with HIV

Very close to Facial nerve !

Causes 

Although there are more than a dozen species of atypical mycobacteria, the two most common are Mycobacterium kansasii and M. avium-intracellulare (MAC). These microbes are found in many places in the environment: tap water, fresh and ocean water, milk, bird droppings, soil, and house dust. The manner in which these bacteria are transmitted is not completely understood. There is no evidence that they are transmitted from person to person.

 MAC, M. kansasii, and M. scrofulaceum may cause inflammation of the lymph nodes in otherwise healthy young children.  Atypical mycobacteria infections can also occur without causing any symptoms. 

Diagnosis

The diagnosis is made from the patient's symptoms and organisms grown in culture from the site of infection.The clinical picture of this infection is commonly very specific. This consists of unilateral submandibular lymphadenopathy in the submaxillary gland area usually associated with erythema of the overlying skin and abscess formation. The age group affected is characteristic 2 to 5 years. The children have minimal systemic symptoms and normal x-rays. Skin tests for atypical organisms are strongly positive; skin tests for Mycobacterium tuberculosis are usually weakly positive.

Treatment

These nontypical mycobacteria are not easy to treat in any patient . Antibiotics are not particularly effective, although rifabutin (a cousin of the anti-tuberculosis drug rifampin) and clofazimine (an anti-leprosy drug) have helped some patients. It is also possible to contain the infection to some degree by combining different drugs, including ethionamide, cycloserine, ethambutol, and streptomycin. Clearly these drugs have significant side effects and may have to be used for 6 months or more

Ideally  Surgical management is the best option. and consists of total excision of involved lymph nodes and skin, closure without drainage, and postoperative drug therapy with clarythromycin.
In the case from the top picture I used a technique of curettage because of the closeness of the marginal mandibular branch of the facial nerve. 

the nodes can be very large

Prognosis

Usually 90% cure rate with simple surgery. those that don't get better require additional medical management.

A new epidemic- Oral cancer due to HPV

We have seen a dramatic rise in our department of patients presenting with oral cancer. This change is in a younger group of patients with P16 positive (Human Papilloma virus) tumours. This is a world-wide phenomenon.

In Sweden the age-standardized incidence of tonsillar cancer increased from 1.3 to 3.6 (2.8-fold) per 100,000 between 1970 and 2002 in the Stockholm area . In men, the increase was 2.6-fold (1.077–2.81 per 100,000), while in women the increase was 3.5-fold (0.232–0.829 per 100,000) 

To learn more about HPV and oral cancer, check out the following infographic from the Mount Sinai Medical Center, USA

Causes, incidence, and risk factors

Oral cancer most commonly involves the tonsils or the tongue. It may also occur on the:

• lips
• Cheek lining
• Floor of the mouth
• Gums (gingiva)
• Roof of the mouth (palate)

Most oral cancers are a type called squamous cell carcinomas. These tend to spread quickly.

Smoking and other tobacco used to cause most cases of oral cancer with Heavy alcohol use also increasing your risk for oral cancer. But now Human papilloma virus (HPV) infection is the commonest cause 

Other factors that may increase the risk for oral cancer include:

• Chronic irritation (such as from rough teeth, dentures, or fillings)
• Taking medications that weaken the immune system (immunosuppressants)
• Poor dental and oral hygiene

Some oral cancers begin as a white plaque (leukoplakia) or as a mouth ulcer.

Men get oral cancer twice as often as women do, particularly men older than 40.

Symptoms

Sore, lump, or ulcer in the mouth:

• Enlarged tonsil with earache
• A lump in the neck often painless
• May be a deep, hard-edged crack in the tissue
• Ulcer on the tongue, lip, or other area of the mouth
• Usually painless at first (may develop a burning sensation or pain when the tumor is advanced)

Other symptoms that may occur with oral cancer include:

• Chewing problems
• Mouth sores
• Pain with swallowing
• Speech difficulties
• Swallowing difficulty
• Swollen lymph nodes in the neck
• Tongue problems
• Weight loss

investigations

• biopsy of the lesion
• FNA of neck node
•  CT scans will be done to determine if the cancer has spread.

Treatment

Surgery to remove the tumor is usually recommended if the tumor is small enough. Surgery may be used together with radiation therapy and chemotherapy for larger tumors. Surgery is not commonly done if the cancer has spread to lymph nodes in the neck.

Other treatments may include speech therapy or other therapy to improve movement, chewing, swallowing, and speech.

Expectations (prognosis)

Approximately half of people with oral cancer will live more than 5 years after they are diagnosed and treated. If the cancer is found early, before it has spread to other tissues, the cure rate is nearly 90%. However, more than half of oral cancers have already spread when the cancer is detected. Most have spread to the throat or neck.

About 1 in 4 persons with oral cancer die because of delayed diagnosis and treatment.

Complications

• Complications of radiation therapy, including dry mouth and difficulty swallowing
• Disfigurement of the face, head, and neck after surgery
• Other spread (metastasis) of the cancer

Govt eyes cuts to elective surgery

In a recent article in the Herald ,the NZ National Health Committee has to find savings of $30 million this financial year from elective procedures deemed to be of little benefit. The New Zealand Government are using data from a  similar committee in Wales. The Welsh Committee has come up with a specific procedures list, under 17 surgical and dental headings, including tonsillectomy, grommets, varicose veins, haemorrhoids, dilatation and curettage, hysterectomy, gallbladder removal, caesarean section, lower-back procedures, circumcision, eye-lid surgery, nose surgery and surgery to correct protruding ears.

The committee said it had completed a technological note on the use of ventilation tube grommets for treating middle-ear infections (otitis media).

"The evidence indicates that the use of ventilation tubes is of limited value in treating otitis media with effusion, although it does not suggest that it should be stopped completely."

BUT when you look at what has happened in UK I found a well written article from the Daily Mail. This talks about the dangers of delaying grommet insertion. New research shows the number of referrals in UK to hospital for treatment of glue ear - a chronic condition that is the biggest single cause of hearing loss in children - has plummeted in the past few years.

The article also  includes information on a New Zealand Study.

"The study of more than 1,000 children born in New Zealand in the early Seventies suggests early glue ear affects behaviour, IQ and reading, into late teens.

It found that compared with 'normal' children, those with a history of glue ear had lower IQ up to the age of 13, more hyperactive and inattentive behaviour up to 15, and reduced reading ability up to 18.

It concluded that 'early middle ear disease history appears to have a deleterious effect on reading ability, verbal IQ and behaviour problems'."

The people of Northland need to be very wary of a new breed of Health Administrator in Wellington, many of whom have recently been exported from UK, who have plans to cut services particularly to the  poorest children in New Zealand.

New Zealand Balance and Dizziness Centre

A few weeks ago I attended the opening of the NZ Balance and Dizziness Centre (NZBDC) in Auckland.

The services on offer include everything from initial assessment through objective diagnosis to rehabilitation. Initial assessment will be by experienced Neuro-Otologists, followed by directed investigations by the Vestibular Audiologist and Vestibular Physiotherapist to allow confirmation of diagnosis and documentation of the degree and severity of the underlying problem.


I was impressed by the quality of the staff running this new clinic as well as the new equipment for diagnosis and treatment.

This is a private facility but may be well worth a patient attending particularly with dizziness of uncertain origin.

Indications for Adenotonsillectomy in Children

The indications for Tonsillectomy have changed over the years with more understanding about the effects of Obstructive Sleep Apnoea (OSA) in children.
The paper published below is from the Paediatrics and Child health Division of the Royal College of Physicians and The Australian Society of Otolaryngology head and Neck Surgery. It was published in 2008 but still relevant today and to the New Zealand Population.

It emphasises the need to increase the access for adenotonsillectomy for children with moderate to severe OSA.

This is in contrast to what is happening in UK where there has been a 40% planned reduction in Adenotonsillectomy. " The operation has been placed on lists of treatments classed as 'of limited benefit' which are being used by primary care trusts to refuse funding on the NHS."
see http://www.telegraph.co.uk/health/healthnews/9195475/NHS-rationing-leaving-thousands-of-children-suffering-tonsillitis-surgeons.html
So I personally believe we need to be wary of any governmental plan to reduce and control the number of T's and Ads. JG


Final Approved Tonsillectomy Document (3)

Head thrust test- an important test for vertigo.

The head impulse or head thrust test was first described by Halmagyi and Curthoys in 1988.  It has acquired an increasingly important place in the clinical examination of the vertigo patient. It detects severe unilateral loss of semicircular canal (SCC) function clinically; it is more sensitive and specific than the traditional Romberg and similar tests; and it is particularly important in the emergency unit, where it can distinguish between vestibular neuritis and cerebellar infarction, which can both generate similar symptoms suggesting an initial attack of severe acute vertigo.
The result of the head thrust test is definitely normal in a patient with a cerebellar infarction but abnormal in a patient with vestibular neuronitis.

                                                                                                                    Kerber K A , Baloh R W Neurol Clin Pract 2011;1:24-33

see youtube video- Halmagyi Head Thrust Maneuver