CPJXXX10.1177/0009922815584945Clinical PediatricsLiu et al

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A Child With Fever and Swelling of the Forehead

Clinical Pediatrics 2015, Vol. 54(8) 803­–805 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922815584945 cpj.sagepub.com

Ann Liu, BS1, Alexander K. Powers, MD1, Amy S. Whigham, MD1, Christopher T. Whitlow, MD, PhD1, and Avinash K. Shetty, MD1

Case Report A 10-year-old previously healthy female presented to the emergency department with a 5-day history of headache and nasal congestion, as well as a 2-day history of fever as high as 104°F and swelling across her forehead. She had initially seen her pediatrician for presumed viral upper respiratory illness but returned to clinic after she developed facial and periorbital swelling the day prior to presentation. At presentation, she was alert and nontoxic appearing with a temperature of 101.6°F (38.7°C), heart rate of 112 beats/min, respirations of 22 breaths/min, blood pressure of 127/86 mm Hg, and an oxygen saturation of 97% on room air. Her examination was notable for boggy tender swelling on the forehead, diffuse swelling of the upper face to the maxilla that was tender to palpation, and periorbital swelling (greater on the left). The rest of the examination was unremarkable. Laboratory data showed elevated white blood cell count (18 200 cells/mm3, with 82% neutrophils). A C-reactive protein (CRP) was elevated at 294 mg/dL (normal = 0-10 mg/dL). A blood culture on admission was negative and chest radiograph was normal. A contrast-enhanced computed tomography (CT) scan of the head and face was obtained (Figures 1 and 2), which showed changes of acute sinusitis with an enhancing fluid collection involving the left maxillary, sphenoid, ethmoid, and frontal sinuses. There was extension of the fluid collection into the left frontal epidural space measuring 2.4 cm × 0.7 cm, consistent with an epidural abscess and extending into the periosteum overlying the frontal bone with locules of gas.

Final Diagnosis Pott’s puffy tumor and epidural abscess complicating frontal sinusitis

Hospital Course Our patient was diagnosed with Pott’s puffy tumor (PPT) with left epidural empyema complicating acute

sinusitis, affecting the frontal sinus, left maxillary antrum, ethmoid, and sphenoid sinuses. The patient underwent emergent left-sided frontal craniotomy, evacuation of the epidural empyema, left maxillary antrostomy, and left anterior ethmoidectomy. Bacterial cultures from the empyema grew alpha-hemolytic Streptococci, sensitive to penicillin, ceftriaxone, vancomycin, and meropenem. Cultures from the left maxillary sinus grew methicillin-susceptible Staphylococcus aureus, sensitive to oxacillin, vancomycin, and meropenem. She was treated for 4 weeks with parenteral meropenem followed by 2 additional weeks of oral cephalexin. At the 2-month follow-up visit, she was well.

Discussion Serious intracranial complications can rarely occur following acute bacterial sinusitis due to the proximity of the paranasal sinuses to the orbit and brain.1 First described in 1760, PPT is characterized by osteomyelitis of the frontal bone associated with subperiosteal abscess.2,3 In the post–antibiotic era, PPT is a rare complication of frontal sinusitis but can also occur after trauma, insect bites, cocaine abuse, dental infection, or fibrous dysplasia.4-6 Anterior spread of infection from the frontal sinus to the bone can occur from direct extension or more frequently via the avalvular diploic veins draining the sinus mucosa, resulting in osteomyelitis of the frontal bone and subperiosteal abscess.7 Retrograde spread of septic thrombi can occur to the dura and brain causing epidural empyema, as noted in our case. Orbital cellulitis or intraorbital abscess can occur if the inferior wall of the frontal sinus is infected.7 PPT is frequently encountered in adolescents, often with a male predominance.8 Classic symptoms include 1

Wake Forest School of Medicine, Winston-Salem, NC, USA

Corresponding Author: Avinash K. Shetty, Department of Pediatrics, Wake Forest School of Medicine, Medical Center Blvd, Winston Salem, NC 27157-1089, USA. Email: [email protected]

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Clinical Pediatrics 54(8)

Figure 1.  Axial non-contrast CT of the paranasal sinuses (A-C) shown in radiological convention, with right and left designated at the bottom of each image as R and L, respectively. Serial images of the paranasal sinuses from cranial (A) to caudal (B) demonstrate opacification of the left frontal (A), sphenoid (A and B), ethmoid (B) and maxillary (C) sinuses.

Figure 2.  Axial contrast-enhanced CT of the brain and scalp showing a low-attenuation extra-axial fluid collection along the frontal calvarium, with thickening and enhancement of the adjacent dura, compatible with an epidural abscess. An additional low-attenuation peripherally enhancing fluid collection containing a locule of gas is present in the deep frontal scalp soft tissues.

fever, headache, rhinitis, and localized, tender, softtissue forehead swelling, but the presentation can be subtle, which can delay diagnosis.4 Most cases are diagnosed around day 7 of the febrile illness.8 Persistent fever, periorbital swelling, symptoms and signs of raised intracranial pressure (eg, vomiting, headache, lethargy, or papilledema), or clinical worsening despite antibiotic therapy warrant the need for imaging to exclude intracranial infection. Lumbar puncture is contraindicated in patients with epidural empyema, in the setting of raised intracranial pressure. Patients with PPT complicated by early intracranial involvement may not exhibit abnormal neurologic symptoms.8 Intracranial complications may include meningitis, epidural or subdural empyema, thrombosis of cortical veins, superior sagittal sinus or cavernous sinus, cerebritis, and infarction.7,8

Early diagnosis of PPT is crucial to prevent intracranial complications of frontal sinusitis. Leukocytosis, elevated erythrocyte sedimentation rate or CRP may be noted in patients with intracranial abscess.8 A contrastenhanced head CT scan can detect intracranial complications, although a magnetic resonance imaging with gadolinium is the test of choice to diagnose parenchymal abscess.7,9 Organisms causing acute or chronic bacterial sinusitis are usually implicated in PPT, including Staphylococcus aureus, Streptococcus species, nontypeable Haemophilus influenzae, and anaerobes (including Bacterioides, Fusobacterium necrophorum).8 Streptococcus anginosus may cause an aggressive intracranial infection associated with sinusitis in children.10 Management of PPT warrants a multidisciplinary approach with consultation from neuroradiology, neurosurgery, otolaryngology, and pediatric infectious diseases. Since infection is often polymicrobial in PPT and epidural empyema, broad-spectrum intravenous antibiotics with good penetration across the blood–brain barrier, surgical drainage of epidural empyema, and the extracranial subperiosteal abscess, in conjunction with sinus drainage via open or endoscopic approaches, is recommended. With increasing reports of communityassociated methicillin-resistant Staphylococcus aureus causing complicated sinus infections, empiric therapy of PPT must include antibiotics that are active against it, such as vancomycin. Vancomycin plus meropenem or vancomycin plus ceftriaxone and metronidazole is an appropriate initial choice for suppurative intracranial complications of sinusitis.9 Culture and antimicrobial susceptibility data are useful to guide antibiotic choice. Patients with PPT associated with epidural empyema need a 4- to 6-week course of intravenous antibiotics. In conclusion, PPT is an unusual complication of frontal sinusitis characterized by osteomyelitis of the frontal bone and associated subperiosteal abscess. Intracranial extension of the infection is a serious complication of

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Liu et al PPT. A multidisciplinary approach with surgical drainage and antibiotic therapy to treat pathogens associated with acute sinusitis remain standard therapy for PPT. Author Contributions All authors were involved in writing the report. AL wrote the first draft of the manuscript. AP, AW and AS cared for the patient. CW made the radiologic diagnosis. AS and CW edited the draft for scientific content.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article

References 1. DeMuri GP, Wald ER. Complications of acute bacterial sinusitis in children. Pediatr Infect Dis J. 2011;30: 701-702.

2. Pott P. Injuries of the Head From External Violence. 1st ed. London, England: C Hitch & L Hawes; 1760:47-48. 3. Tattersall R. Pott’s puffy tumour. Lancet. 2002;359: 1060-1063. 4. Tudor RB, Carson JP, Pulliam MW, Hill A. Pott’s puffy tumor, frontal sinusitis, frontal bone osteomyelitis, and epidural abscess secondary to a wrestling injury. Am J Sports Med. 1989;9:390-391. 5. Raja V, Low C, Sastry A, Moriarty B. Pott’s puffy tumor following an insect bite. J Postgrad Med. 2007;53: 114-116. 6. McDermott C, O’Sullivan R, McMahon G. An unusual cause of headache: Pott’s puffy tumour. Eur J Emerg Med. 2007;14:170-173. 7. Wells RG, Sty JR, Landers AD. Radiological evaluation of Pott’s puffy tumor. JAMA. 1986;255:1330-1333. 8. Tsai BY, Lin KL, Lin TY, et al. Pott’s puffy tumor in children. Childs Nerv Syst. 2010;26:53-60. 9. Adame N, Hedlund G, Byington CL. Sinogenic intracranial empyema in children. Pediatrics. 2005;116:e461-e467. 10. Deutschmann MW, Livingstone D, Cho JJ, Vanderkooi OG, Brookes JT. The significance of Streptococcus anginosus group in intracranial complications of pediatric rhinosinusitis. JAMA Otolayngol Head Neck Surg. 2013;139:157-160.

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A Child With Fever and Swelling of the Forehead. Pott's puffy tumor and epidural abscess complicating frontal sinusitis.

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