Pott puffy tumor Pranav Sharma, MD, Salil Sharma, MD, Nishant Gupta, MD, Puneet Kochar, MD, and Yogesh Kumar, MD
Pott puffy tumor is osteomyelitis of the frontal bone with associated subperiosteal abscess causing swelling and edema over the forehead and scalp. It is a complication of frontal sinusitis or trauma. We present the case of an 8-year-old girl with frontal swelling. Imaging evaluation showed frontal osteomyelitis as a complication of frontal sinusitis with associated epidural and subperiosteal abscess. The patient was treated surgically and recovered well. This case highlights the need for high clinical suspicion and early diagFigure 1. Sagittal CT of the brain with (a) bone window and (b) soft tissue window images shows erosion of the nosis and management to prevent life- outer and inner cortices of frontal bone (arrow) with prefrontal soft tissue swelling (arrow). threatening complications. Unfortunately, in our case the patient had to undergo surgery for this complication, and underwent craniotomy with trephination and drainage of the brain abscess. Functional endoscopic sinus surgery with a which could have been prevented by earlier diagnosis.
ott puffy tumor is a rare complication of sinusitis characterized by osteomyelitis of the frontal bone with subperiosteal abscess presenting as frontal swelling. It was ﬁrst described by Sir Percival Pott in 1768 in relation to frontal head trauma. Later, it was established that this entity is more common in relation to frontal sinusitis (1). We report a case of an 8-year-old girl who presented with gradually increasing frontal swelling. CASE REPORT An 8-year-old girl was referred for persistent headaches and gradually increasing frontal swelling for 3 days. She had sinusitis 1 month earlier and was treated with azithromycin. She had multiple drug allergies to penicillin, cephalosporin, and cotrimoxazole. A computed tomography (CT) scan revealed frontal sinusitis with cortical erosions and frontal subperiosteal and epidural soft tissue swelling (Figure 1). Magnetic resonance imaging (MRI) revealed frontal sinusitis, frontal bone defect, and frontal epidural collection with peripheral rim enhancement suggestive of epidural abscess (Figure 2). A small subperiosteal abscess was also noted in the frontal soft tissues. The patient was started on intravenous antibiotics Proc (Bayl Univ Med Cent) 2017;30(2):179–181
left ethmoidectomy and frontal and maxillary antrostomy was also performed. Culture of the pus revealed Streptococcus intermedius. The follow-up MRI revealed resolution of subperiosteal and epidural abscesses (Figure 3). DISCUSSION Pott puﬀy tumor is a rare clinical entity with the advancement in antibiotic treatment. Initially described with head trauma, now it is known to be associated with untreated or partially treated sinusitis; however, cases due to mastoid surgery, dental infections, wrestling injuries, and insect bites have been reported (2, 3). Pott puﬀy tumor can be found in all age groups, but occurs predominantly in adolescents (4). Frontal sinuses are often pneumatized by 2 years of age and are approximate adult size by the late teens. Venous drainage occurs through diploic veins that have communication with the dural venous sinuses, which can propagate septic emboli (4). These infections From the Department of Radiology, Yale New Haven Health at Bridgeport Hospital, Bridgeport, Connecticut (P. Sharma, S. Sharma, Kochar, Kumar); and the Department of Radiology, St. Vincent’s Medical Center, Bridgeport, Connecticut (Gupta). Corresponding author: Yogesh Kumar, MD, Department of Radiology, Yale New Haven Health at Bridgeport Hospital, 267 Grant Street, Bridgeport, CT 06610 (e-mail: [email protected]
reduction. A CT scan with contrast can be performed if there is a high suspicion of intracranial extension. Intracranial complications with or without direct erosion of the frontal bone have been observed in about 60% to 85% of these patients (5, 7). Tsai et al reported a 100% rate of intracranial complications in their six pediatric patients with Pott puﬀy tumor (8). Ketenci et al indicated that intracranial complications are often present during a regimen of antibiotics and are often asymptomatic when the abscess is localized Figure 2. (a) Sagittal T2 fluid-attenuated inversion recovery and (b) axial contrast-enhanced T1-weighted images in a silent area of the central nervous show frontal sinusitis (smaller arrow), frontal bone defect (curved arrow), and frontal epidural collection (longer system (5, 9, 10). arrow) with peripheral rim enhancement (larger double arrows) suggestive of epidural abscess. A small subperiosteal CT scan can demonstrate siabscess is also noted in the frontal soft tissues (smaller double arrows). nusitis, bone erosion, subperiosteal collection, and intracranial extenare often polymicrobial, with streptococci, staphylococci, and sion. In our case, CT showed frontal sinusitis, bone erosion, anaerobic bacteria, as they favor lower oxygen concentrations. subperiosteal collection, and extradural abscess. As with other Hence, antibiotic coverage should include gram-positive and intracranial pathologies, MRI is the modality of choice (11, 12). anaerobes (5). In the present case, the organism was Streptococcus MRI can better delineate intracranial pathology, dural sinus intermedius. thrombosis, and bone edema. Abscesses show restricted diﬀuSymptoms include headache, periorbital swelling, fever, sion (13, 14) on diﬀusion-weighted sequences, indicating thick purulent rhinorrhea, vomiting, and signs of meningitis or enviscous pus. In this case, MRI showed frontal bone edema and cephalitis. Intracranial complications occur either due to direct extradural abscess, without dural venous sinus or meningeal inextension or venous drainage. Complications include meningivolvement. MRI is helpful particularly in follow-up after meditis; epidural, subdural, or intraparenchymal abscess; and caverncal or surgical management, reducing overall radiation exposure. ous sinus and dural venous sinus thrombosis (5). If the inferior Bone scintigraphy with Tc-mMP may be more sensitive than wall of the frontal sinus is involved, infection may spread to the CT in detection of early osteomyelitis, but its sensitivity is poor orbits, causing either orbital cellulitis or intraorbital abscess (6). in the setting of acute sinusitis (15). Our patient presented with frontal swelling and headache Early diagnosis and treatment of Pott puﬀy tumor is necesin the emergency department and received a CT. Although sary. Broad-spectrum antibiotics for 4 to 6 weeks, along with CT scans have a higher radiation dose, at most centers like surgical drainage, is the standard of care. This patient underwent ours, MRI scanners are not available around the clock. Parfrontal craniotomy and functional endoscopic sinus surgery ticular attention should be paid to decrease the radiation dose in addition to 4 weeks of antibiotics. Follow-up MRI showed by strictly following the pediatric protocols for radiation dose complete resolution. b
Figure 3. Postoperative postcontrast (a) axial and (b) sagittal MRI images show resolution of the extradural abscess and frontal sinus infection. The burr holes (arrows) are related to surgical evacuation of the abscess. 180
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1. Goldberg AN, Oroszlan G, Anderson TD. Complications of frontal sinusitis and their management. Otolaryngol Clin North Am 2001;34(1):211–225. 2. 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 1981;9(6):390–391. 3. Raja V, Low C, Sastry A, Moriarty B. Pott’s puﬀy tumor following an insect bite. J Postgrad Med 2007;53(2):114–116. 4. Gupta M, El-Hakim H, Bhargava R, Mehta V. Pott’s puﬀy tumour in a preadolescent child: the youngest reported in the post-antibiotic era. Int J Pediatr Otorhinolaryngol 2004;68(3):373–378. 5. Ketenci I, Unlü Y, Tucer B, Vural A. The Pott’s puﬀy tumor: a dangerous sign for
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intracranial complications. Eur Arch Otorhinolaryngol 2011;268(12):1755– 1763. 6. Nisa L, Landis BN, Giger R. Orbital involvement in Pott’s puﬀy tumor: a systematic review of published cases. Am J Rhinol Allergy 2012;26(2):e63–e70. 7. Ibarra S, Aguirrebengoa K, Pomposo I, Bereciartúa E, Montejo M, González de Zárate P. [Osteomyelitis of the frontal bone (Pott’s puﬀy tumor). A report of 5 patients.] Enferm Infecc Microbiol Clin 1999;17(10):489–492. 8. Tsai BY, Lin KL, Lin TY, Chiu CH, Lee WJ, Hsia SH, Wu CT, Wang HS. Pott’s puﬀy tumor in children. Childs Nerv Syst 2010;26(1):53–60. 9. Verbon A, Husni RN, Gordon SM, Lavertu P, Keys TF. Pott’s puﬀy tumor due to Haemophilus inﬂuenzae: case report and review. Clin Infect Dis 1996;23(6):1305–1307. 10. Reynolds DJ, Kodsi SR, Rubin SE, Rodgers IR. Intracranial infection associated with preseptal and orbital cellulitis in the pediatric patient. J AAPOS 2003;7(6):413–417.
11. Gourineni VC, Juvet T, Kumar Y, Bordea D, Sena KN. Progressive multifocal leukoencephalopathy in a 62-year-old immunocompetent woman. Case Rep Neurol Med 2014;2014:549271. 12. Kumar Y, Hooda K, Li S, Karol I, Muro GJ. A case of spontaneous intracranial hypotension: the role of dynamic CT myelography and epidural blood patch in diagnosis and treatment. Conn Med 2015;79(9):547–549. 13. Kumar Y, Wadhwa V, Phillips L, Pezeshk P, Chhabra A. MR imaging of skeletal muscle signal alterations: systematic approach to evaluation. Eur J Radiol 2016;85(5):922–935. 14. Kumar Y, Khaleel M, Boothe E, Awdeh H, Wadhwa V, Chhabra A. Role of diﬀusion weighted imaging in musculoskeletal infections: current perspectives. Eur Radiol 2017;27(1):414–423. 15. Uren RF, Howman-Giles R. Pott’s puﬀy tumor: scintigraphic ﬁndings. Clin Nucl Med 1992;17(9):724–727.
Pott puffy tumor