Pott's Puffy Tumor and Epidural Abscess Arising from Pansinusitis

Pott's puffy tumor of the upper eyelid misdiagnosed as simple abscess: a case report and literature review

A 76-year-old woman, initially thought to have a simple abscess on her right upper eyelid, presented to our department of plastic and reconstructive surgery. Enhanced three-dimensional facial computed tomography (CT) revealed an abscess on the right upper lid, with a pyomucocele present in the right frontal sinus, accompanied by bone erosion in the superior wall of the right orbit. Based on the results of the CT scan, we diagnosed an atypical Pott's puffy tumor (PPT) with an abscess on the upper lid originating from the frontal sinusitis. First, surgical incision and drainage were performed in our department, and a percutaneous vacuum drain was placed. To provide a more definitive treatment, endoscopic sinus surgery (ESS) was subsequently performed by otorhinolaryngologists. The patient was discharged without any complications 5 days after ESS. At a 1-year follow-up, no recurrence or notable neurological symptoms were observed. In the case we observed, the patient presented with an upper eyelid abscess and cellulitis, indicating possible orbital involvement. For such patients, a CT scan is necessary. Given the possibility of PPT, it is critical to perform a comprehensive differential diagnosis rather than defaulting to a straightforward approach involving abscess treatment.

A Systematic Review of Intracranial Complications in Adults with Pott Puffy Tumor over Four Decades

The purpose of this study is to investigate the risk factors of intracranial complications in adult patients with Pott Puffy Tumor (PPT). A systematic review was conducted of clinical studies from January 1983 to December 2022 that reported on PPT adult patients. The full-text articles were reviewed for the patients’ ages, sex, cultured organisms, surgical procedures, clinical sequalae, and underlying diseases that may affect the onset of intracranial complications in PPT adult patients. A total of 106 studies were included. Medical data were reviewed for 125 patients (94 males, 31 females). The median age was 45 years. A total of 52% had comorbidities, mostly head trauma (24.5%), sinus/neurosurgical operations (22.4%), immunosuppression conditions (13.3%), diabetes mellitus (9.1%), cocaine use (7.1%), or dental infections (6.1%). A total of 28 cultures revealed Streptococcus (22.4%), 24 contained staphylococci (19.2%), and 22 cultures contained other pathogens (17.6%). An amount of 30.4% developed intracranial complications, with the most common being epidural abscesses or empyemas (55.3%), as well as subdural (15.7%) and extradural lesions (13.2%). Age, DM, and immunosuppression conditions are significantly associated with intracranial complications (p < 0.001, p = 0.018 and p = 0.022, respectively). Streptococcus infection is associated with intracranial complications (p = 0.001), although Staphylococcus and other microorganisms are not. Surgical intervention, mainly ESS, and broad-spectrum antibiotics remain the cornerstones of treatment.

Intracranial empyema complicating sinusitis in childhood: Epidemiology, imaging findings and outcome

BACKGROUND

To describe clinical presentations of intracranial sinusitis complications in childhood, their pitfalls and imaging findings.

MATERIEL AND METHODS

This retrospective IRB-approved single-center study included infants diagnosed with sinusitis and empyema and/or other intracranial complications who underwent imaging between September 2008 and September 2019. Three radiologists individually reviewed clinical charts and imaging findings, including sinusitis complications and at-risk anatomical variations.

RESULTS

21 children (76% males and 24% females, mean age 13±3.1 years) with imaging pansinusitis were included. Headache (95%) and fever (90%) were the main clinical nonspecific signs. Ten (48%) children presented an extradural empyema, nine (43%) children had a subdural empyema and two (10%) children had both. Frontal location sinusitis was the most common (76%). In MRI, all empyema presented as a hypo intensity on pre-contrast T1-WI, a hyperintensity on T2-WI, a reduced apparent diffusion coefficient (ADC) on diffusion weighted imaging (DWI) and a peripheral contrast enhancement on post-contrast T1-WI. CT or MRI revealed intracranial complications such as a collection size increase (52%), a midline shift (62%), intraparenchymal abscesses (24%), a cerebral venous thrombosis (29%), an intracranial pressure increase (29%), cerebral ischemia (43%) and Pott's Puffy Tumor (10%). Imaging highlighted sinus anatomical abnormalities in 52% of cases. All children were treated with sinus drainage and/or neurosurgery. Long-term follow-up was favorable in 14 cases (67%).

CONCLUSION

Complications of sinusitis are life threatening in the studied population. Empyema and cerebral complications may be misleading. Brain contrast-enhanced CT covering sinuses and orbits, is mainly the first examination done but MRI is mandatory.

A Case of Pott's Puffy Tumor Associated With Barosinusitis From Scuba Diving

ABSTRACT

Barosinusitis, or sinus barotrauma, is a well-described condition associated with changes in barometric pressure during flight and diving that can result in sinonasal mucosal injury. In this case report, we present an adolescent who experienced barosinusitis during scuba diving and subsequently developed Pott's puffy tumor (PPT), characterized by frontal sinusitis, frontal bone osteomyelitis, and overlying subperiosteal abscess. This unique case of PPT following scuba diving provides the opportunity to review the pathophysiology of both barotrauma-induced sinus disease and PPT, a rare and unreported serious complication of barosinusitis. Furthermore, we discuss how scuba diving and associated barosinusitis can be considered a risk factor in the development of PPT.

Pott's puffy tumor caused by Actinomyces naeslundii

Pott’s puffy tumor is characterized by forehead swelling from subperiosteal abscess and frontal bone osteomyelitis. It is encountered mainly in children; rarely in adults. When it does occur in the latter population, the most common risk factors include head trauma, sinusitis, or cocaine abuse. Generally, the organisms thought to be involved include streptococci, staphylococci and oral anaerobic flora. We present a case of a 53 year old female who presented with forehead swelling of 3 month duration after a dental procedure, found to be secondary to Actinomyces naeslundii. Actinomyces is a very rare etiology of this disease and has been reported only twice earlier in the literature. We present an uncommon infectious disease along with summary of clinical characteristics of this entity in the adult population.

Pott's Puffy Tumor and Intranasal Cocaine Abuse

Pott's puffy tumor (PPT) is a rare subperiosteal abscess of the frontal bone with osteomyelitis, which most commonly affects adolescents as a complication of frontal sinusitis or head trauma. The Authors describe a case of development of a PPT in a woman who abused of cocaine for at least five years and presented with a gradually enlarging mass of the forehead. The patient was treated surgically through combined endoscopic and open approach and medically with antibiotic therapy. The PPT, as rare complication of intranasal cocaine abuse, was described until now in four patients. Even rare it can be a fearsome complication, making of fundamental importance an early diagnosis and a correct management.

Not just a bump on the head: ultrasound as first-line imaging in a boy with Pott's puffy tumour

While computed tomography (CT) and magnetic resonance imaging (MRI) have established roles in evaluating Pott's puffy tumour, ultrasound can play a valuable role in identifying the condition, particularly in children. We present the case of a boy with a fluctuant forehead lump and headaches, where ultrasound was the first-line imaging modality and expedited further investigations.

Pott Puffy Tumor in Children: A Rare Emergency Clinical Entity

OBJECTIVES

Pott puffy tumor (PPT) is defined as soft tissue swelling of the forehead due to subperiosteal edema, accumulation of pus, or granulation tissue. It is associated with osteomyelitis of frontal bone secondary to frontal sinusitis. Pott puffy tumor can be complicated by preseptal and orbital cellulitis and intracranial infection.

METHODS

Six patients diagnosed with and treated for PPT in Pediatric Clinic of Uludag University Faculty of Medicine from 2010 to 2015 were reviewed retrospectively. Age, sex, presenting symptoms and signs, laboratory and radiological findings, as well as intracranial complications and treatment modalities of all patients were evaluated.

RESULTS

The authors present 6 pediatric patients of PPT, 5 males and 1 female with a mean age of 11 years (age range, 7-18 years). All patients presented with headache, fever, and tender frontal swelling. Two of the patients had epidural abscess and 1 had preseptal orbital cellulitis in addition to PPT. All of them had computed tomography scan and/or magnetic resonance imaging. Endoscopic sinus surgery was performed in 4 patients and 2 patients underwent neurosurgical intervention with antibiotherapy.

CONCLUSIONS

Pott puffy tumor may be associated with potentially dangerous intracranial complications. Early diagnosis and treatment are essential to reduce morbidity and mortality. Imaging plays an important role in the diagnosis of the disease and the detection of its complications.

Subcutaneous emphysema after vigorous sneezing in the setting of acute frontal sinusitis

INTRODUCTION

Subcutaneous emphysema [SCE] can develop due to traumatic, infectious, and spontaneous causes and usually localizes to the periorbital space.

CASE

We present a case of an 18-year-old male with an 8-day history of migraine-like headaches followed by the acute onset of frontofacial swelling after vigorous sneezing. Radiologic and physical exam findings supported a diagnosis of frontofacial SCE in the setting of frontal sinusitis.

DISCUSSION

A sneeze, although usually benign, causes a significant increase in intranasal pressure. When coupled with a history significant for facial trauma or rhinosinusitis, this rise in pressure can be sufficient to cause fracturing of the bone overlying a paranasal sinus, leading to the formation of SCE.

An Uncommon Complication of Sinusitis in a Young Adolescent

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.

Fever and neurologic conditions

Neurologic conditions are categorized as either those that cause a change in mental status or those that create a focal finding on physical examination. Neurologic abnormality associated with fever can be caused by a primary neurologic condition or one that does not originate in the central nervous system. Optimal management of such conditions requires high clinical suspicion and a broad differential diagnosis, which facilitates rapid recognition and effective treatment. A thorough history and physical examination are key determinants in accurately diagnosing neurologic conditions associated with fever, often requiring acquisition of collateral information from persons other than the patient.

Orbital Involvement in Pott's Puffy Tumor: A Systematic Review of Published Cases

Background

Pott's puffy tumor (PPT) is a frontal subperiosteal abscess associated with underlying frontal bone osteomyelitis. It represents a well-known source of sinogenic intracranial infection, but the orbital complications related to this entity are rarely reported. The goal of this study was to characterize the orbital involvement in PPT.

Methods

We performed a systematic review through a Medline search (1950–2010). The authors reviewed all cases of PPT, selecting those explicitly describing orbital complications associated with PPT.

Results

We screened 139 articles, of which 93 reported cases of PPT. Of these, 35 articles described a total of 42 cases presenting simultaneous orbital complications. Eyelid and/or periorbital edema was the most common finding in patients with orbital involvement, and preseptal cellulitis is by far the most prevalent orbital complication in PPT. Postseptal involvement (orbital cellulitis, subperiosteal abscess of the orbit, and orbital abscess) is much rarer. Although treatment of the classic PPT is surgical, only a minority of patients with orbital infection required orbital drainage. Most reported patients made a full recovery, without permanent sequelae.

Conclusion

Orbital infections are possible in patients with PPT. In contrast to surgical treatment of the frontal subperiosteal abscess, the orbital complications can be treated conservatively most of the time. Early diagnosis and aggressive therapy of the underling PPT are essential to avoid severe local or systemic complications.

Pott's puffy tumor in children

INTRODUCTION

Pott's puffy tumor is characterized by subperiosteal abscess associated with osteomyelitis of frontal bone. Reports are limited for this rare entity in the antibiotics era but increase during past decade.

METHODS

We had clinical analysis of a series with six consecutive pediatric patients of Pott's puffy tumor during 20 years in a tertiary medical center via retrospective chart review. One case was described in detail.

RESULTS

Male-to-female ratio was 5:1. The mean age at the time of diagnosis was 13 years-3 months. The risk factors were acute sinusitis in two (33%), chronic sinusitis in two (33%), recent head trauma in two (33%), and acupuncture therapy on skull in one (17%). The commonest presenting symptoms were fever, headache, forehead tenderness, vomiting, and fatigue/malaise (100%). Pott's puffy tumor was diagnosed on average the seventh day after fever, and half had intracranial involvement at diagnosis. All had intracranial infections, and most of them had subdural empyema. The most often involved sinus was frontal sinus (100%). The frontal lobe was the most common site of intracranial infection (100%), two thirds of which are polymicrobial from two or more sites. The initial operation was performed on average on the 5.8th days after diagnosis. Half of the patients underwent reoperation. The mortality rate was 17% (one of six).

CONCLUSION

The symptoms of Pott's puffy tumor are inconspicuous even though early intracranial involvement often occurred. The importance of early diagnosis and aggravated and prompt treatment with prolonged antibiotic therapy is emphasized for better outcome.