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

Incidental MRI and CT findings in paranasal sinuses and mastoid cells

With increasing numbers of CT and MRI scans being performed, this has lead to an  increase in diagnosis of Sinusitis and Mastoiditis being made and referral to our department.
 Fluid signal in the mastoid can be an incidental finding on T2-weighted magnetic resonance imaging and often is interpreted as mastoiditis by radiologists. 

A recent study examined 28 consecutive cases of such erroneously diagnosed "mastoiditis" and documents the presence or absence of otologic symptoms and clinical signs. They found a very low prevalence of otologic symptoms or pathology and no cases of mastoiditis in these patients, and they determined that magnetic resonance imaging is not an effective screening modality for mastoiditis.

Another study showed 61 % of children had one or more salient findings in their paranasal sinuses or mastoid cells. 48 % had mucosal swelling in their paranasal cavities, 25 % in their mastoid cells. The prevalence was higher among children less than 10 years of age (60 % and 42 %) and among children with current upper respiratory tract infection (71 % and 35 %). There was no correlation to a history of headache, snoring, asthma and allergies, or to gender or place of residence.

CONCLUSION:

Mucosal swelling in paranasal sinuses and in mastoid cells is a frequent incidental finding in adults and more commonly in children. Even major mucosal swelling in a paranasal sinus is not necessarily a sign of infection. In radiological reports the terms "sinusitis" and "mastoiditis" should therefore be used with great caution. The initiation of treatment should be based on clinical symptoms and not on radiological abnormalities alone.