Case: A 12 year old male with a history of autism spectrum disorder and chronic sinusitis presents for forehead swelling. Mother reports that she noticed progressive forehead swelling for about 1 month. She has followed up with the patient’s pediatrician and ENT and given oral cephalexin and fluticasone nasal spray which has not made any changes in symptoms. Patient denies any fevers or headache. Vitals include BP 100/58, HR 90, Temp 97.4F, RR 18, SpO2 98%. Exam is notable for a 3x3cm area of fluctuance centrally located over the forehead with no drainage or surrounding erythema that is minimally tender to palpation.
Differential diagnosis includes: abscess, cyst, lipoma
CT of the facial bones with contrast:
CT interpretation: “Bifrontal and ethmoid sinusitis associated with osseous destruction resulting in a 5 cm bifrontal complex loculated anterior epidural abscess as well as a 3 cm midline frontal subgaleal extracranial scalp abscess. Findings are most consistent with osteomyelitis of the frontal bone and sinuses.”
Case continued: ENT and Neurosurgery are emergently consulted and both recommend transfer to a Pediatric Center for advanced surgical and medical management given extensive nature of infection and reconstruction required post-operatively. The patient is started on broad spectrum antibiotics with vancomycin, ceftriaxone, and metronidazole and transferred to a Pediatric Center ICU with neurosurgical consultation. He was taken to the OR for a bifrontal craniotomy for epidural abscess evacuation and did well post-operatively, discharged on hospital day #4.
Pearls:
- Pott’s puffy tumor is a rare, life-threatening complication of frontal sinusitis characterized by osteomyelitis of the frontal bone with associated subperiosteal abscess causing swelling and edema over the forehead and scalp.
- It can be found in all age groups but most common in adolescents.
- MRI brain with and without contrast is the preferred imaging modality due to increased sensitivity to detect early intracranial and osseous abnormalities.
- Treatment is typically surgical intervention with at least 6 weeks of intravenous antibiotics.
- The infection is typically polymicrobial warranting gram-positive, gram-negative, and anaerobic antibiotic coverage.
References:
Sharma, P., Sharma, S., Gupta, N., Kochar, P., & Kumar, Y. (2017). Pott puffy tumor. Proceedings (Baylor University. Medical Center), 30(2), 179–181. https://doi.org/10.1080/08998280.2017.11929575
Masterson L, Leong P. Pott’s puffy tumour: a forgotten complication of frontal sinus disease. Oral Maxillofac Surg. 2009;13(2):115-117. doi:10.1007/s10006-009-0155-7
