ULTRASOUND CASE REVIEW Associate Editor: Jennifer R. Marin, MD, MSc
An Uncommon Complication of Sinusitis in a Young Adolescent Amos J. Shemesh, MD,* Nova L. Panebianco, MD,* and Aaron E. Chen, MD† Abstract: A young adolescent patient presented to the emergency department with forehead and eyelid swelling after a week of nasal discharge that was suspicious for Pott's puffy tumor. Point-of-care ultrasound facilitated rapid diagnosis and initiation of treatment for a concerning and rare complication of sinusitis, confirmed by computed tomography scan. Key Words: PPT, Pott's puffy tumor, sinusitis, frontal bone (Pediatr Emer Care 2015;31: 531–532)
CASE PRESENTATION An 11-year-old boy with no significant medical history presented to the emergency department with 1 day of forehead and bilateral eyelid swelling after 1 week of nasal discharge. He had no recent history of fever, headache, vomiting, vision changes, allergies, or trauma. Physical examination revealed forehead and periorbital edema, no overlying erythema, and a normal neurological examination (Fig. 1). Vital signs were notable only for a mildly elevated temperature of 38.2°C. Laboratory tests revealed a mildly elevated white blood cell count and C-reactive protein. Point-of-care ultrasound of the forehead swelling was performed demonstrating a subgaleal fluid collection (Fig. 2). A computed tomography (CT) scan of the head and sinuses with intravenous contrast was performed and showed an extracranial frontal bone subperiosteal abscess (Fig. 3).
US FINDINGS Ultrasonography of the forehead swelling demonstrated a hypoechoic subcutaneous lesion measuring 6 19 mm consistent with subperiosteal abscess overlying thickened frontal bone.
FIGURE 1. The forehead and periorbital edema.
depending on the location. Most distal from the probe is hyperechoic bone with complete shadowing posteriorly.
REVIEW OF THE LITERATURE The differential diagnoses for a patient with forehead and periorbital swelling includes angioedema, cellulitis, trauma, and hypoproteinemic states such as nephrotic syndrome. Pott's puffy tumor (PPT) is an uncommon but serious entity that can result from frontal sinusitis, characterized by subperiosteal abscess of the frontal region. Presenting symptoms include frontal scalp swelling, headaches, fever, nasal drainage, photophobia, and frontal sinus tenderness. Patients often fail antibiotic therapy for sinusitis,
TECHNIQUE Point-of-care ultrasonography was performed with a Mindray M7 machine using a high-frequency linear-array transducer at the position of soft tissue swelling on the forehead. Scanning was performed in the longitudinal and transverse planes to localize and measure the lesion. With soft tissue ultrasound of the forehead, the epidermis and dermis appear as a thin hyperechoic layer closest to the probe, followed by the hypoechoic subcutaneous fat and fibrous tissue. Deep to the skin and subcutaneous tissues, fascia may be seen as a hyperechoic line of variable thickness
From the *Department of Emergency Medicine, Hospital of the University of Pennsylvania; and †Department of Pediatric Emergency Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. Disclosure: The authors declare no conflict of interest. Reprints: Amos J Shemesh, MD, Department of Emergency Medicine, Hospital of the University of Pennsylvania, 3400 Spruce St, Ground Silverstein, Philadelphia, PA 19104 (e‐mail: [email protected]; [email protected]). Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0749-5161
FIGURE 2. Ultrasonography of the forehead swelling with a high-frequency linear-array transducer demonstrating a hypoechoic subcutaneous lesion measuring 6 19 mm consistent with subperiosteal abscess overlying the frontal bone.
Pediatric Emergency Care • Volume 31, Number 7, July 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.pec-online.com
531
Pediatric Emergency Care • Volume 31, Number 7, July 2015
Shemesh et al
subperiosteal soft tissue masses and aid in localizing and determining the extent of infection and its severity.4 While literature describing the use of point-of-care ultrasound for PPT is limited, ultrasound in the detection of subperiosteal abscess in children with acute osteomyelitis has been described and proposed as a means of distinguishing normal periosteum from that, which is elevated by pus, and potentially obviating the need for surgical intervention.7
CONCLUSIONS There is an increasingly evolving role for point-of-care ultrasound of musculoskeletal infections and their complications in the emergency department. Ultrasound may potentially have value in ruling out PPT and avoiding unnecessary CT and may improve treatment outcomes by hastening this diagnosis, timely administration of antibiotic therapy, and otorhinolaryngology intervention, especially when used as an adjunct to traditional imaging modalities.4 FIGURE 3. Computed tomography scan of the head with intravenous contrast demonstrating the presence of subperiosteal abscess within the subcutaneous tissue overlying the frontal bone (see labels). 1–3
and most require surgical intervention. Infection travels from the sinuses via valveless diploic veins to the dural venous plexus and periosteum of the cranial and periorbital spaces.4 Infection can potentially extend to both intracranial and extracranial spaces to cause a periorbital and orbital cellulitis, meningitis, intracranial abscess, and sinus venous thrombosis.1 Soft tissue swelling with periosteal thickening is an early sign of the infectious progression on ultrasound, followed by increasing periosteal thickening, subperiosteal exudate, abscess, and cortical erosion.4–6 Musculoskeletal infections as a whole are common in clinical practice and are amenable to ultrasound, which can evaluate
532
www.pec-online.com
REFERENCES 1. Bannon PD, McCormack RF. Pott's puffy tumor and epidural abscess arising from pansinusitis. J Emerg Med. 2011;41:616–622. 2. Bambadakis NC, Cohen AR. Intracranial complications of frontal sinusitis in children: Pott's puffy tumor revisited. Pediatr Neurosurg. 2001;35:82–89. 3. Goldberg AN, Oroszlan G, Anderson TD. Complications of frontal sinusitis and their management. Otolaryngol Clin North Am. 2001;34:211–225. 4. Weinberg B, Gupta S, Thomas MJ, et al. Pott's puffy tumor: Sonographic diagnosis. J Clin Ultrasound. 2005;33:305–307. 5. Chau CL, Griffith JF. Musculoskeletal infections: ultrasound appearances. Clin Radiol. 2005;60:149–159. 6. Wright NB, Abbott GT, Carty HM. Ultrasound in children with osteomyelitis. Clin Radiol. 1995;50:623–627. 7. Howard CB, Einhorun MS. Ultrasound in the detection of subperiosteal abscesses. J Bone Joint Surg Br. 1991;73:175–176.
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
An Uncommon Complication of Sinusitis in a Young Adolescent Amos J. Shemesh, MD,* Nova L. Panebianco, MD,* and Aaron E. Chen, MD† Abstract: A young adolescent patient presented to the emergency department with forehead and eyelid swelling after a week of nasal discharge that was suspicious for Pott's puffy tumor. Point-of-care ultrasound facilitated rapid diagnosis and initiation of treatment for a concerning and rare complication of sinusitis, confirmed by computed tomography scan. Key Words: PPT, Pott's puffy tumor, sinusitis, frontal bone (Pediatr Emer Care 2015;31: 531–532)
CASE PRESENTATION An 11-year-old boy with no significant medical history presented to the emergency department with 1 day of forehead and bilateral eyelid swelling after 1 week of nasal discharge. He had no recent history of fever, headache, vomiting, vision changes, allergies, or trauma. Physical examination revealed forehead and periorbital edema, no overlying erythema, and a normal neurological examination (Fig. 1). Vital signs were notable only for a mildly elevated temperature of 38.2°C. Laboratory tests revealed a mildly elevated white blood cell count and C-reactive protein. Point-of-care ultrasound of the forehead swelling was performed demonstrating a subgaleal fluid collection (Fig. 2). A computed tomography (CT) scan of the head and sinuses with intravenous contrast was performed and showed an extracranial frontal bone subperiosteal abscess (Fig. 3).
US FINDINGS Ultrasonography of the forehead swelling demonstrated a hypoechoic subcutaneous lesion measuring 6 19 mm consistent with subperiosteal abscess overlying thickened frontal bone.
FIGURE 1. The forehead and periorbital edema.
depending on the location. Most distal from the probe is hyperechoic bone with complete shadowing posteriorly.
REVIEW OF THE LITERATURE The differential diagnoses for a patient with forehead and periorbital swelling includes angioedema, cellulitis, trauma, and hypoproteinemic states such as nephrotic syndrome. Pott's puffy tumor (PPT) is an uncommon but serious entity that can result from frontal sinusitis, characterized by subperiosteal abscess of the frontal region. Presenting symptoms include frontal scalp swelling, headaches, fever, nasal drainage, photophobia, and frontal sinus tenderness. Patients often fail antibiotic therapy for sinusitis,
TECHNIQUE Point-of-care ultrasonography was performed with a Mindray M7 machine using a high-frequency linear-array transducer at the position of soft tissue swelling on the forehead. Scanning was performed in the longitudinal and transverse planes to localize and measure the lesion. With soft tissue ultrasound of the forehead, the epidermis and dermis appear as a thin hyperechoic layer closest to the probe, followed by the hypoechoic subcutaneous fat and fibrous tissue. Deep to the skin and subcutaneous tissues, fascia may be seen as a hyperechoic line of variable thickness
From the *Department of Emergency Medicine, Hospital of the University of Pennsylvania; and †Department of Pediatric Emergency Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. Disclosure: The authors declare no conflict of interest. Reprints: Amos J Shemesh, MD, Department of Emergency Medicine, Hospital of the University of Pennsylvania, 3400 Spruce St, Ground Silverstein, Philadelphia, PA 19104 (e‐mail: [email protected]; [email protected]). Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0749-5161
FIGURE 2. Ultrasonography of the forehead swelling with a high-frequency linear-array transducer demonstrating a hypoechoic subcutaneous lesion measuring 6 19 mm consistent with subperiosteal abscess overlying the frontal bone.
Pediatric Emergency Care • Volume 31, Number 7, July 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.pec-online.com
531
Pediatric Emergency Care • Volume 31, Number 7, July 2015
Shemesh et al
subperiosteal soft tissue masses and aid in localizing and determining the extent of infection and its severity.4 While literature describing the use of point-of-care ultrasound for PPT is limited, ultrasound in the detection of subperiosteal abscess in children with acute osteomyelitis has been described and proposed as a means of distinguishing normal periosteum from that, which is elevated by pus, and potentially obviating the need for surgical intervention.7
CONCLUSIONS There is an increasingly evolving role for point-of-care ultrasound of musculoskeletal infections and their complications in the emergency department. Ultrasound may potentially have value in ruling out PPT and avoiding unnecessary CT and may improve treatment outcomes by hastening this diagnosis, timely administration of antibiotic therapy, and otorhinolaryngology intervention, especially when used as an adjunct to traditional imaging modalities.4 FIGURE 3. Computed tomography scan of the head with intravenous contrast demonstrating the presence of subperiosteal abscess within the subcutaneous tissue overlying the frontal bone (see labels). 1–3
and most require surgical intervention. Infection travels from the sinuses via valveless diploic veins to the dural venous plexus and periosteum of the cranial and periorbital spaces.4 Infection can potentially extend to both intracranial and extracranial spaces to cause a periorbital and orbital cellulitis, meningitis, intracranial abscess, and sinus venous thrombosis.1 Soft tissue swelling with periosteal thickening is an early sign of the infectious progression on ultrasound, followed by increasing periosteal thickening, subperiosteal exudate, abscess, and cortical erosion.4–6 Musculoskeletal infections as a whole are common in clinical practice and are amenable to ultrasound, which can evaluate
532
www.pec-online.com
REFERENCES 1. Bannon PD, McCormack RF. Pott's puffy tumor and epidural abscess arising from pansinusitis. J Emerg Med. 2011;41:616–622. 2. Bambadakis NC, Cohen AR. Intracranial complications of frontal sinusitis in children: Pott's puffy tumor revisited. Pediatr Neurosurg. 2001;35:82–89. 3. Goldberg AN, Oroszlan G, Anderson TD. Complications of frontal sinusitis and their management. Otolaryngol Clin North Am. 2001;34:211–225. 4. Weinberg B, Gupta S, Thomas MJ, et al. Pott's puffy tumor: Sonographic diagnosis. J Clin Ultrasound. 2005;33:305–307. 5. Chau CL, Griffith JF. Musculoskeletal infections: ultrasound appearances. Clin Radiol. 2005;60:149–159. 6. Wright NB, Abbott GT, Carty HM. Ultrasound in children with osteomyelitis. Clin Radiol. 1995;50:623–627. 7. Howard CB, Einhorun MS. Ultrasound in the detection of subperiosteal abscesses. J Bone Joint Surg Br. 1991;73:175–176.
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
