Forehead swelling in a teenage boy Patrick Stark,1 Raymun Ghumman,1 Alexandra Thomas2 and Susan M Sawyer1,3,4 1 4

Centre for Adolescent Health, 2Department of Otolaryngology, Royal Children’s Hospital, 3Department of Paediatrics, The University of Melbourne and Murdoch Children’s Research Institute, Melbourne, Victoria, Australia

Key words:

adolescent; cerebral abscess; ENT; Pott’s puffy tumour.

Case Report A previously well, fully immunised 14-year-old boy presented to the emergency department after a 2-day history of increasing central forehead and upper eyelid swelling associated with fever and frontal headache. There was no nausea, vomiting or coryza, no history of recent trauma and no known sick contacts. Examination revealed a low grade temperature (37.8C) with normal pulse rate, respiratory rate and blood pressure. Periorbital swelling was present bilaterally with swelling and tenderness over his frontal sinus (see Fig. 1a). There was no eye discharge, disturbance of visual acuity, proptosis, ophthalmolplegia, diplopia or limitation of eye movements. His conjunctivae were not injected, and ear, nose and throat examination was unremarkable. Initial investigations demonstrated a slightly elevated C reactive protein (34 mg/L) with normal full blood examination. He was admitted for observation and commenced on intravenous flucloxacillin and simple analgesia. After 48 h, the bilateral periorbital swelling and forehead swelling had increased with bilateral periorbital erythema also noted (see Fig. 1b). Given clinical progression despite intravenous antibiotics, multiplanar multisequence pre-contrast computerised tomography (CT) imaging of his brain was performed followed by CT venography. This revealed a subperiosteal abscess in the frontal

Learning Points 1 Pott’s puffy tumour is a rare condition that typically affects adolescents. 2 Symptoms include swelling of the forehead, headache, purulent rhinorrhoea and fever. 3 Diagnosis is confirmed with CT imaging of the orbits, sinuses and brain. 4 Treatment involves narrow spectrum, targeted antibiotics and surgical drainage. 5 Undiagnosed or only partially treated, the complications can be significant including meningitis, intracranial abscess formation and venous sinus thrombosis. Correspondence: Dr Patrick Stark, Centre for Adolescent Health, Royal Children’s Hospital, 50 Flemington Road, Parkville, Vic. 3052, Australia. Fax: 03 9345 9600; email: [email protected] Conflict of interest: No conflict of interest. Accepted for publication 22 October 2014.

region (Pott’s puffy tumour) with extensive adjacent subcutaneous tissue oedema and thickening (see Fig. 2). Consultation with the Ear, Nose and Throat team resulted in commencement of intravenous dexamethasone, Nasonex (Merck, Whitehouse Station, NJ, USA) and Nasal Flo washes (Unilab, Mandaluyong City, Philippines). Subsequently incision and drainage through the eyebrows was performed under general anaesthetic, as well as an intranasal approach for drainage of the maxillary sinus with uncinectomy via a swing door technique. Penrose drains were inserted and remained in situ for 48 h. Definitive tissue diagnosis via culture showed profuse growth of Staphylococcus aureus (methicillin resistant), following which antibiotic coverage was changed to clindamycin and rifampicin. Significant clinical improvement was noted within 24 h of surgery. He was discharged 3 days postoperatively (see Fig. 1c) to complete antibiotics at home with daily medical review. This continued for a total of 6 weeks at which point he was reviewed in outpatient clinic and had made a complete recovery.

Discussion Pott’s puffy tumour refers to a well-circumscribed forehead swelling with subperiosteal abscess formation and osteomyelitis. It was originally described by Percivall Pott in 1760 as ‘a puffy indolent circumscribed tumor of the scalp and a spontaneous separation of the pericranium, from the skull under such tumor’.1 Although now relatively rare since the advent of antibiotics, some reports suggest its incidence has been increasing over the past decade.1,2 It is thought to occur secondary to acute or chronic frontal sinusitis and has also been associated with trauma.2,3 Adolescents are the population cohort most commonly affected, with the peak age of incidence reported between 11 and 14.5 years.3,4 It is extremely rare in the preteenage cohort,5 which is thought to reflect the relative late development of the frontal sinuses;6 the pneumatised frontal sinuses can be distinguished radiologically from the ethmoid sinuses only around 6–8 years of age with further development continuing over the following 8–10 years.6 Symptoms experienced by patients with this condition can include swelling of the forehead and or scalp, rhinorrhoea, headache and fever as well as general malaise.2 Signs of raised intracranial pressure secondary to the intracranial abscess may also be present. Indeed of the seven patients described by Kombogiorgas and Solanki, four presented with neurological symptoms including hemiparesis, obtundation, pupillary dilatation and aphasia.

Journal of Paediatrics and Child Health 51 (2015) 731–733 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)


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Fig. 1 Progression of facial swelling. (a) Day of presentation; (b) day 3 of admission and (c) day 2 post drainage.

Fig. 2

The choice of investigations should be determined by the extent of clinical suspicion. In the case of uncomplicated acute bacterial rhino-sinusitis, investigations to determine the pathogen are not normally required, nor are imaging studies, as neither would change management. However, if a Pott’s puffy tumour is clinically suspected, then microbiological studies via subcutaneous or sinus aspiration may help target choice of antibiotics. Typical pathogens are the same as those found in bacterial rhino-sinusitis, which include Streptococcus pneumoniae, Haemophilus influenzae (non-typeable) and Moraxella catarrhalis.7 Imaging should be performed if a Pott’s puffy tumour is clinically suspected. This would involve contrast-enhanced CT imaging of the orbits, sinuses and brain.6 CT imaging typically demonstrates an opacified frontal sinus with stranding accompanied by swelling of the overlying scalp.8 Defects in the anterior wall of the frontal sinus may be further elucidated with appropriate bone algorithms.8 Magnetic resonance imaging studies may need to be considered depending if there is neurological involvement. Appropriate imaging would confirm the diagnosis and help to determine subsequent definitive treatment. In a 20-year retrospective review (1989–2009) at a teriary children’s hospital in Taiwan, Tsai et al. reported six cases of Pott’s puffy tumour where the diagnosis was made on an average of 7 days after the onset of fever following CT imaging that confirmed the clinical suspicion.1 732

CT brain with IV contrast.

In addition to narrow spectrum antibiotic coverage based on empiric evidence, treatment also involves surgical incision and drainage. Ongoing antibiotic coverage may be appropriately targeted depending on the isolation of the pathogen. Typically antibiotic coverage is continued for 6–8 weeks following the surgical drainage.1,3,9 The vast majority of patients treated appropriately for Pott’s puffy tumour recover without major sequelae.4 The mean length of stay is 2 weeks, ranging from 10 to 21 days.3 Although relatively rare, if undiagnosed or only partially treated, complications can be significant including meningitis, intracranial abscess formation and venous sinus thrombosis.2,4,10 Tsai et al. reported that one of their six patients who underwent surgical drainage died.1 This case highlights the importance of clinical suspicion in making the diagnosis of this relatively rare condition that most commonly presents in adolescents.

References 1 Tsai BY, Lin KL, Lin TY et al. Pott’s puffy tumor in children. Childs Nerv. Syst. 2010; 26: 53–60. 2 Kombogiorgas D, Solanki G. The Pott puffy tumor revisited: neurosurgical implications of this unforgotten entity. J. Neurosurg. 2006; 105: 143–9. 3 Parida PK1, Surianarayanan G, Ganeshan S, Saxena SK. Pott’s puffy tumor in pediatric age group: a retrospective study. Int. J. of Pediatr. Otorhinolaryngol. 2012; 76: 1274–7.

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4 Bambakidis N, Cohen A. Intracranial complications of frontal sinusitis in children: Pott’s puffy tumor revisited. Pediatr. Neurosurg. 2001; 35: 82–9. 5 Gupta M, El-Hakim H, Burgava R, Mehta V. Pott’s puffy tumor in a pre-adolescent child: the youngest reported in the post-antibiotic era. Int. J. of Pediatr. Otorhinolaryngol. 2004; 68: 373–8. 6 Wald E. Rhinitis and acute and chronic sinusitis. In: Bluestone CD, Stool SE, Sheetz MD, eds. Pediatric Otolaryngology, 2nd edn. Philadelphia, PA: Saunders, 1990; 843–73. 7 Cherry J, Mundi J, Shapiro N. Rhinosinusitis. In: Cherry JD, Harrision GJ, Kaplan SL et al., eds. Feigin and Cherry’s Textbook of Pediatric Infectious Diseases, 7th edn. Philadelphia, PA: Elsevier Saunders, 2014; 193–203. 8 Durur-Subasi I, Kantarci M, Karakaya A. et al. Pott’s puffy tumor: multidetector computed tomography findings. J. Craniofac. Surg. 2008; 19: 1697–9. 9 Masterson L, Leong P. Pott’s puffy tumour: a forgotten complication of frontal sinus disease. Oral Maxillofac. Surg. 2009; 13: 115–17. 10 Remmler D, Bolen R. Intracranial complications of frontal sinusitis. Laryngoscope 1980; 90: 1814–24.

Multiple Choice Questions 1. The incidence of Pott’s puffy tumour is? a. Highest in infancy (1–12 month of ages) b. Highest in early childhood (2–5 years of age) c. Highest in late childhood (5–10 years of age) d. Highest in teenagers (12–19 years of age) e. Distrubuted bimodally with peaks at 3 months and 16 years of age Answer: d Pott’s puffy tumour may affect all age groups; however, it is most commonly found in teenages.

Forehead swelling in a teenager

2. Symptoms of Pott’s puffy tumour typically include all of the following except? a. Headache and photophobia b. Swelling of the forehead c. Fever d. Purulent rhinorrhoea e. Otorrhoea Answer: e Symptoms of Pott’s puffy tumour typically include headache, photophobia, swelling of the forehead, fever, purulent rhinorrhoea and potentially signs of raised intracranial pressure secondary to the intracrial abscess. Otorrhoea is not a typlical symptom. 3. When Pott’s puffy tumour is clinically suspected the next most appropriate step is? a. To commence simple analgesia and reassure as this condition is thought to be self resolving b. To commence daily oral antihistamines for 5 days (e.g. cetirizine) c. To commence oral antibiotics (e.g. amoxycillin + clavulanic acid) and a organise a follow up appointment in 4–6 weeks to confirm resolution d. To start intravenous antibiotics (eg fluxcloxacillin) and organise a multiplanar, multisequence pre-contrast CT of the skull and sinuses e. Immediate emergency incision and drainage Answer: d On clinical suspicion of Pott’s puffy tumour, it is recommended narrow spectrum intravenous antibiotics are started and a multiplanar, multisequence pre-contrast CT of the skull and sinuses be performed to confirm the presense of a collection.

Journal of Paediatrics and Child Health 51 (2015) 731–733 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)


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