An Uncommon Complication of Sinusitis in a Young Adolescent

Point-of-Care Ultrasound Evaluation of Pediatric Osteomyelitis in the Emergency Department: A Case Series

ABSTRACT

Musculoskeletal and soft tissue complaints commonly present to the pediatric emergency department and literature supports the use point-of-care ultrasound (POCUS) in the diagnosis of these complaints. The diagnosis of osteomyelitis typically involves laboratory testing with inflammatory biomarkers, imaging with x-ray, and often magnetic resonance imaging with test results often not immediately available. We report a case series of children initially evaluated with POCUS for osteomyelitis. The POCUS may expedite diagnosis and treatment when used as the initial test in children with suspected osteomyelitis in the emergency department.

Pott's Puffy Tumor: A Rare, Life-Threatening Presentation of Periorbital Edema

Pott's puffy tumor (PPT) describes forehead swelling with associated frontal bone osteomyelitis and a subperiosteal abscess (SPA) requiring a high suspicion index for optimal outcomes. PPT is a life-threatening complication of frontal sinusitis typically found in adolescents. Our case is one of the youngest in the literature. This report describes a 3-year-old patient who developed multifocal abscesses in the epidural space with frontal and orbital SPA, requiring surgical intervention. Additionally, her course was complicated by a superior sagittal venous thrombosis, a complication commonly associated with PPT. We present an unusual case of orbital SPA and aim to highlight a life-threatening pediatric condition that is often underrecognized.

Unusual Presentation of Pott's puffy tumour in a child: our recent experience and review of the literature

Pott's puffy tumour (PPT) is a rarely seen, but highly important, complication of frontal sinusitis. Early recognition followed by prompt imaging and treatment of this condition are essential to improve patient outcomes and prevent complications. This case report describes an atypical presentation of radiologically confirmed PPT in a boy who presented with a 2.5-week history of progressive frontal headache and midline frontal swelling. Flexible nasendoscopy revealed no acute findings. Prompt CT imaging confirmed the diagnosis and early surgical intervention via endoscopic approach with aggressive antibiotic therapy led to good recovery. This case highlights the need to remember PPT in assessing any child or adolescent with a new forehead swelling, with or without sinusitis symptoms. If there is strong clinical suspicion, further imaging should not be delayed. Surgical intervention should be performed as early as possible to prevent intracranial complications; antibiotics alone are not sufficient.

The Use of Point-of-care Ultrasound in the Diagnosis of Pott's Puffy Tumor: A Case Report

INTRODUCTION

Pott's puffy tumor (PPT) is a rare clinical disease characterized by forehead swelling from a subperiosteal abscess coupled with frontal bone osteomyelitis. It is often associated with severe complications and poor outcomes if left undiagnosed; thus, rapid recognition is crucial. Point-of-care ultrasound (POCUS) may provide an alternative pathway to diagnosis. It can be performed rapidly at the bedside and assist in early screening of patients, identifying those with high suspicion for PPT and prioritizing imaging and consultation.

CASE REPORT

A 59-yghb ar-old-male presented to the emergency department for evaluation of a "lump" on his forehead. He recently had a bifrontal craniotomy to de-bulk a polyp burden in an effort to manage his recurrent sinusitis. To further characterize the mass, a POCUS examination was performed by the treating emergency physician. The examination found a subcutaneous, hypoechoic fluid collection extending superficially along the frontal bone. A discontinuity in the surface of the frontal bone was visualized through which the collection appeared to extend. Given the heightened concern for PPT based on the POCUS examination findings, otolaryngology service was consulted and the patient was admitted for further imaging and treatment.

CONCLUSION

Pott's puffy tumor is a rare diagnosis that has the potential for life-threatening complications. Timely diagnosis is imperative. Point-of-care ultrasound can easily be used to help identify patients with suspicion for PPT in the acute care setting and influence patient management with regard to obtaining further imaging and plans for early consultation.

Pott's Puffy Tumor

Pott's puffy tumor is a potential complication of acute frontal sinusitis, characterized by subperiosteal abscess and osteomyelitis of the frontal bone. It can be managed with a combination of open and endoscopic sinus surgery and intravenous antibiotic therapy. In the current report, a 15-year-old male presented with a classic case of Pott's puffy tumor which was managed with bilateral ethmoidectomies, frontal sinusotomies, and frontal sinus trephination, resulting in discharge on intravenous antibiotic therapy and subsequent complete resolution of symptoms.

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.

Acute bacterial sinusitis in children: an updated review

Background

In the pediatric age group, approximately 7.5% of upper respiratory tract infections (URIs) are complicated by acute bacterial sinusitis (ABS). Despite its prevalence, ABS is often overlooked in young children. The diagnosis and management present unique challenges in primary care. This is an updated narrative review on the evaluation, diagnosis, and management of ABS.

Methods

A PubMed search was performed using the key term ‘acute sinusitis’. The search strategy included clinical trials, meta-analyses, randomized controlled trials, observational studies, and reviews. The search was restricted to the English literature and children.

Results

Haemophilus influenzae (non-typeable), Streptococcus pneumoniae, and Moraxella catarrhalis are the major pathogens in uncomplicated ABS in otherwise healthy children. In complicated ABS, polymicrobial infections are common. The diagnosis of acute sinusitis is mainly clinical and based on stringent criteria, including persistent symptoms and signs of a URI beyond 10 days, without appreciable improvement; a URI with high fever and purulent nasal discharge at onset lasting for at least 3 consecutive days; and biphasic or worsening symptoms.

Conclusion

Data from high-quality studies on the management of ABS are limited. The present consensus is that amoxicillin-clavulanate, at a standard dose of 45 mg/kg/day orally, is the drug of choice for most cases of uncomplicated ABS in children in whom antibacterial resistance is not suspected. Alternatively, oral amoxicillin 90 mg/kg/day can be administered. For those with severe ABS or uncomplicated acute sinusitis who are at risk for severe disease or antibiotic resistance, oral high-dose amoxicillin-clavulanate (90 mg/kg/day) is the drug of choice.

Pott Puffy Tumor in Adults: The Τiming of Surgical Ιntervention

Pott’s puffy tumor (PPT) represents a rare complication of frontal sinusitis, and it is considered as a subperiosteal abscess of the frontal bone based on osteomyelitis.

We report two adult PPT patients and discuss the treatment plan as well as the correct timing of surgical intervention. Clinical examination revealed sinusitis with puss, and imaging findings showed bony erosion of the dorsal wall of the frontal sinus in both patients. In case 1, a “wait and see” approach was followed with remission of the patient’s symptoms, and a Draf IIb type was performed 21 days after discharge. In case 2, worsening of symptoms led to surgical drainage through a Lynch incision followed by 20 days of intravenous antibiotic treatment. Then a Draf type IIa was performed. Both patients received antibiotic therapy over the course of six weeks and had full recovery.

We highlight the importance of the correct timing of surgical intervention as it is depended on the clinical and radiological findings. The timing to performing radical drainage surgery including external or endoscopic frontal sinus surgery is not determined in the literature. Worsening of common symptoms and neurological signs in adult PPT patients means by default an immediate surgical intervention. Reduction of symptoms and antibiotic treatment response means that surgery should be delayed and performed in a surgical field free of inflammation.

Pott's puffy tumor in children: A review of the literature

OBJECTIVES

Pott's puffy tumor (PTT) is a frontal subperiosteal abscess associated with underlying frontal osteomyelitis. The purpose of the present study was to assess the rate of intracranial involvement in pediatric and adolescent patients with PPT and to discuss the diagnostic workup and the therapeutic features of this pathology.

METHODS

We searched Web of Science, PubMed and MEDLINE from 1998 to 2018. The search focused on papers concerning the diagnostic procedure and therapeutic management of PTT. Statistical techniques were not used.

RESULTS

We included 53 articles that described 92 pediatric and adolescent patients with PPT. The overall rate of intracranial complications was found to be 72%. Most authors used computed tomography for the diagnosis of PTT and its complications, either alone or in combination with magnetic resonance imaging. In 50% of cases, an endoscopic endonasal approach is used for the management of the underlying acute or chronic sinusitis.

CONCLUSIONS

On the basis of the available literature, it seems that the incidence rate of intracranial involvement in patients with PPT is quite high. Early diagnosis using the appropriate imaging raise the possibility of good recovery. Concerning the therapy of PTT, endoscopic sinus surgery could be considered as a valuable technique. The vast majority of patients treated appropriately recover without long-term neurologic complications and sequelae.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:225-231, 2020.

Neurosurgical Management of Pott's Puffy Tumor in an Obese Adolescent with Asthma: Case Report with a Brief Review of the Literature

Pott’s puffy tumor is a rare and severe complication of frontal sinusitis, characterized by the progressive swelling of the frontal soft tissues secondary to a subperiosteal abscess. Radiological imaging with ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) are important diagnostic tools in establishing diagnosis and treatment planning. Early surgery along with intravenous antibiotics are required in order to achieve a good recovery. The authors report a case of Pott’s puffy tumor in an obese 14-year-old male, with a previous history of asthma and a chronic use of steroids, treated with neurosurgical debridement followed by a combined course of intravenous (IV) and oral antibiotics, who had a favorable outcome upon long-term follow-up. In addition, a brief review of the current medical literature was performed for a discussion on the diagnostic and therapeutic features of this pathology.

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.