Pott Puffy Tumor

A previously healthy 15-year-old boy presented to the emergency department with a fever of 40°C, vomiting, severe right-sided eye pain, headache, and visual changes.

Physical examination revealed swelling of the right periorbital region that was fluctuant, erythematous, warm, and painful to the touch. The extraocular muscles were intact, and ocular movements were not associated with pain. No active discharge from the eyes or noses was apparent. The rest of the physical examination results were normal. The boy had no history of facial or head trauma, recurrent sinus infections, or dental caries. His immunizations were up to date.

Laboratory test results demonstrated leukocytosis, with a white blood cell count of 23,400/µL (90% polymorphonuclear leukocytes), along with an elevated C-reactive protein (CRP) level of 349 mg/L and an elevated erythrocyte sedimentation rate (ESR) of 53 mm/h. The hemoglobin level and the results of coagulation studies and a comprehensive metabolic panel were unremarkable.

Computed tomography (CT) of the face exhibited extensive right periorbital and facial swelling and extensive right-sided maxillary and ethmoid sinus disease. Magnetic resonance imaging (MRI) of the brain exhibited multiple abscesses in the periorbital region and the presence of a subdural empyema.

Based on his presentation and these test results, the patient was given the diagnosis of Pott puffy tumor (PPT).

PPT is osteomyelitis of the frontal bone that is commonly associated with a subperiosteal abscess. The condition can be secondary to trauma, mastoiditis, insect bites, and malignancy but most commonly is related to complications of acute or chronic sinusitis.^1,2

Patients with PPT typically present with a relatively indolent course of symptoms consisting of headaches, rhinorrhea, and fever.^1,2 They may have no history of trauma, vomiting, visual disturbances, seizures, or other focal neurologic deficits. However, the common concern is the formation of a localized, fluctuant, erythematous swelling of the forehead. Laboratory test findings usually exhibit leukocytosis and elevated CRP and/or ESR.^1-3

The diagnostic modality of choice is contrast-enhanced CT of the frontal, nasal, and paranasal sinuses. CT scans will help identify the presence of any extracranial or intracranial complications. If intracranial involvement is visualized on CT results, MRI is recommend to further highlight the extension of the disease.^1-3

Sinus cultures obtained intraoperatively most often are polymicrobial, with ɑ-hemolytic and β-hemolytic streptococci, staphylococci, and Haemophilus influenzae. In cases of intracranial complications, the most commonly found organisms are Fusobacterium, Bacteroides, and anaerobic streptococci.^1,3

Treatment for PPT consists of broad-spectrum antibiotics and surgical intervention. The most commonly used antibiotics are ceftriaxone, vancomycin, and metronidazole. After culture sensitivity test results are obtained, antibiotic therapy can be tailored appropriately.^2,3

In our patient’s case, incision and drainage of the right frontal temporofacial abscess was done. He was started on ceftriaxone, metronidazole, and vancomycin. Two weeks later, despite the antibiotic regimen, the subdural abscess had progressed. Craniotomy and evacuation of the abscess then were performed. Intracranial and extracranial cultures obtained at that time grew Streptococcus intermedius. The antibiotic regimen was changed accordingly to linezolid, rifampin, and ceftriaxone. Our patient’s condition markedly improved, and after a 4-week hospital stay, he was discharged home with an additional 2 weeks of antibiotic therapy.

The relative rarity of Pott puffy tumor can lead to delayed diagnosis and treatment. However, this condition is a surgical emergency; it is imperative to immediately begin broad-spectrum antibiotic therapy with surgical intervention to avoid long-term neurologic sequelae, morbidity, and mortality.

REFERENCES

1. Haider HR, Mayatepek E, Schaper J, Vogel M. Pott’s puffy tumor: a forgotten differential diagnosis of frontal swelling of the forehead. J Pediatr Surg. 2012;47(10):1919-1921.

2. Suwan PT, Mogal S, Chaudhary S. Pott’s puffy tumor: an uncommon clinical entity. Case Rep Pediatr. 2012;2012:386104. doi:10.1155/2012/386104.

3. Parida PK, Surianarayanan G, Ganeshan S, Saxena SK. Pott’s puffy tumor in pediatric age group: a retrospective study. Int J Pediatr Otorhinolaryngol. 2012;76(9):1274-1277.