Minimally Invasive Surgery for Pott's Puffy Tumor: Is It Time for a Paradigm Shift in Managing a 250-Year-Old Problem?

A Case of Pott's Puffy Tumor in a Patient With Eosinophilic Chronic Rhinosinusitis

Eosinophilic chronic rhinosinusitis (ECRS) is a refractory type 2 inflammation-based airway allergic disease that is prone to complications such as bronchial asthma. Pott's puffy tumor (PPT) is a rare clinical entity characterized by osteomyelitis of the frontal bone accompanied by a subperiosteal abscess. A 56-year-old female with a history of cranial surgery and bronchial asthma presented to an otolaryngology clinic with nasal obstruction and loss of smell, later developing swelling and redness on her forehead. She was diagnosed and treated for ECRS and was thought to have developed PPT during her course. Nasal endoscopy reveals bilateral polyp formation originating from the middle meatus. Paranasal computed tomography (CT) indicates substantial swelling extending from the opening of the frontal sinus to the adjacent subcutaneous tissue, accompanied by a defect in the frontal bone and osteolysis at the base of the frontal skull. Her management included conservative antibiotic therapy adjusted due to a drug eruption and, subsequently, endoscopic sinus surgery (ESS). The case was complicated by the patient's medical history and the absence of detailed surgical records, which limited the use of enhanced imaging techniques. This underscores the complexity of diagnosing and managing PPT in adults, particularly those with prior surgeries, emphasizing the need for a tailored diagnostic and therapeutic approach that integrates detailed patient history with current clinical indicators to effectively guide treatment. This case contributes to the limited literature on adult PPT and underscores the critical need for careful patient monitoring and detailed surgical history.

An Endoscopic Approach for Frontal Sinus Cutaneous Fistula With Completely Ossified Frontal Recess

A frontal sinus cutaneous fistula (FSCF) is a rare and challenging condition. Remarkable advancements in endonasal endoscopic surgery (EES) have enabled the treatment paradigm for a FSCF to gradually shift from open procedures to ESS. Nevertheless, the experience of EES for a post-trephination-related FSCF is rare, especially in patients with a pronounced frontal recess (FR) ossification. Here, we report an endoscopic strategy for successfully treating a post-trephination-related FSCF with complete ipsilateral FR neo-osteogenesis. Through two surgical corridors created by the modified mini-Lothrop procedure and an ipsilateral frontal osteotomy window, we established a patent drainage pathway from the affected side to the opposite side. This strategy may prevent potential orbital and cranial base injuries from affecting the ossified region of the ipsilateral FR. Moreover, in addition to the advantage of aesthetic outcomes, the procedure allows a single-stage surgery and facilitates the debridement and surveillance of the wound through the drainage pathway postoperatively. In conclusion, this technique could be a feasible endoscopic strategy for a FSCF, regardless of the severity of the FR ossification.

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.

Case Report: Pott's Edematous Tumor: Complicated Frontal Sinusitis - An Unremembered Diagnosis

Pott’s Puffy tumor, also called Pott’s edematous tumor (PET), is a subperiosteal abscess of the frontal bone, associated with osteomyelitis of the frontal bone. In this paper, we report the case of a 16-year-old patient who presented with headache associated with progressive forehead swelling and fever. Clinical and imaging exams pointed to the hypothesis of PET associated with brain abscess. Patient was submitted to surgical excision of the abscess and treatment of osteomyelitis, with intraoperative findings corroborating the condition. There was a good clinical-radiological recovery associated with prolonged antibiotic therapy and satisfactory follow-up after hospital. PET, which often results from an underdiagnosed or partially treated frontal sinusitis, is a condition that must be promptly recognized and directed to an adequate therapeutic approach due to the risk of serious complications that it entails.

Pott's puffy tumor: A comprehensive review of the literature

PURPOSE

Pott's puffy tumor (PPT) is a rare clinical entity characterized by osteomyelitis of the frontal bone with subperiosteal abscess collection. The frequency of reported cases of PPT in the literature has increased in recent years. Previous reviews of PPT exist primarily in the form of small, retrospective case series and anecdotal case reports. Therefore, the aim of this study is to provide the literature's largest comprehensive, up-to-date review of the essential clinical findings, diagnostic modalities, microbiologic considerations, and treatment approaches utilized in the management of PPT, both in pediatric and adult populations.

MATERIALS AND METHODS

We searched MEDLINE, PubMed, and Embase databases for English-language studies published from January 1950 through January 30, 2022. The authors reviewed all cases of PPT, focusing specifically on those describing therapeutic management of PPT. A total of 321 patients were included, consisting of 318 patients (from 216 articles) and an additional 3 adult cases from our institution.

RESULTS

PPT most often results from untreated rhinosinusitis, as well as direct head trauma, substance use, and odontogenic disease. Infections are classically polymicrobial with an anaerobe-predominant microbiome. Both CT and MRI imaging modalities are commonly obtained for presurgical assessment of sinusitis and intracranial extension. The core of treatment is an early and aggressive approach to prevent long-term complications. A significant association exists between surgical management and clinical outcomes for patients with PPT. Recent literature suggests endoscopic sinus surgery is essential for successful disease resolution.

CONCLUSIONS

PPT is an important and relatively morbid disease process that is often underrecognized and misdiagnosed at presentation due to its variable clinical presentation. Management of PPT includes both antimicrobial therapy and surgical intervention. Determination of the optimal approach depends on patient clinical features including age, history of prior endoscopic sinus surgery, and presence of intracranial involvement on presentation. An individualized, targeted, and interdisciplinary approach to the treatment of PPT is critical for successful disease resolution.

Incidence of Odontogenic Disease in Patients With Pott's Puffy Tumor

PURPOSE

Osteomyelitis with subperiosteal abscess of the frontal bone, or Pott's puffy tumor (PPT), is a rare but life-threatening condition. The relationship of concurrent dental disease to PPT has not been well described. This study sought to delineate the incidence of odontogenic disease in PPT, especially in cases where there is no history of facial trauma or prior frontal sinus surgery.

METHODS

A retrospective chart review of patients diagnosed with PPT between 2010 and 2019 was carried out. Demographics, pertinent medical history, surgical procedures performed, and microbial cultures and antibiotics used were extracted for analysis. Maxillofacial computed tomography scans were reviewed for presence of odontogenic disease.

RESULTS

A total of 17 patients were identified. Four had documented history of frontal bone trauma; 3 had previous frontal sinus surgery. Seven (41%) had documented odontogenic disease on initial radiology reports; however, upon dentist review, 16 (94%) had various pathology visible on their computed tomography scans. Twelve of these 16 patients had no previous frontal sinus trauma or surgery. Eight patients (47%) had only ipsilateral maxillary or ethmoid inflammation respective to PPT on computed tomography. Seventy-six percent of patients underwent endoscopic sinus surgery. Of 14 patients with cultures collected at the time of surgery, 7 (50%) had polymicrobial growth and 6 (43%) had anaerobic growth.

CONCLUSIONS

The incidence of odontogenic disease in this population of PPT was 94%. In the absence of a history of frontal bone trauma or frontal sinus surgery, underlying dental origin should be suspected in cases of PPT. Initial radiology reports may not document all identifiable dental pathology. Therefore, patients presenting with PPT should undergo comprehensive evaluation, including an oral cavity and dental examination, and potential referral to dental colleagues.

Pautas de tratamiento del tumor inflamatorio de Pott. Revisión bibliográfica

Introducción y objetivo: El objetivo de este estudio es proporcionar una revisión actualizada del tratamiento médico y quirúrgico en pacientes con abscesos subperiósticos secundarios a la osteomielitis del hueso frontal. Método: Se realizó una búsqueda en la base de datos PubMed, BVS (biblioteca virtual en salud España) y Scopus de las distintas opciones terapéuticas del tumor de Pott. La revisión se realizó siguiendo los criterios PRISMA. Resultados: Se seleccionaron 20 artículos en la búsqueda bibliográfica. Un total de 30 pacientes (24 varones, con media de edad de 27 años) fueron revisados. En un 90% la causa fue una rinosinusitis crónica, seguida por traumatismos locales. En la mayoría de los casos se realizó un drenaje endoscópico tipo Draf 2 (60%), 5 pacientes fueron sometidos a un Draf 3, tres a un Draf 1 y sólo uno a un Draf 2B. Un paciente fue tratado con sinuplastia con balón y otro con craneotomía externa aislada. Todos los pacientes tenían antibióticos orales o intravenosos de duración variable; aunque predomina el esquema terapéutico de vancomicina y ceftriaxona endovenosa durante 6 semanas. No hubo más complicaciones después de la intervención endoscópica sinusal. La presencia de fístulas, cicatrizaron sin necesidad de desbridamiento quirúrgico o cierre. Discusión: el tumor inflamatorio de Pott es una patología muy infrecuente. Debido a la rareza de la patología, muchos casos han sido infradiagnosticados desembocando en complicaciones intracraneales. El abordaje externo ha sido el tratamiento de elección durante años; actualmente se aboga por un abordaje endonasal guiada en ocasiones por neuronavegador sumado a la antibioticoterapia correspondiente durante un largo periodo de tiempo. Conclusiones: La mayoría de los casos de tumor inflamatorio de Pott pueden manejarse endoscópicamente. La disponibilidad de instrumentos en ángulo motorizados, videos de alta definición y sistemas de guía de imágenes han proporcionado a los otorrinolaringólogos una alternativa creíble a las técnicas tradicionales. Además, la biodisponibilidad mejorada de los antibióticos puede obviar la necesidad de una craneotomía y drenajes externos.

Draf III frontal sinus surgery for the treatment of Pott's puffy tumour in adults: our case series and a review of frontal sinus anatomy risk factors

Purpose

We present our case series of four adult patients with Pott’s puffy tumour (PPT), successfully treated with Draf III over a mean period of 11 months. A critical review of the literature is also provided.

Methods

A retrospective review of patients undergoing Draf III for PPT from January 2018 to January 2019 was performed.

Results

Four consecutive male patients ranging from 26 to 62 years, with a mean age of 49.5 ± 16.3 years, undergoing Draf III for Pott’s puffy tumour were included. Two patients had a Kuhn type IV frontal cell narrowing the frontonasal pathway and presented without previous sinus surgery, whereas the other two had previous sinus surgery. The success rate of the operation was 100% with an average length of follow-up of 11 months (range 5–18).

Conclusion

In our experience, the Draf III procedure is a highly effective treatment of PPT. In particular, we have demonstrated it to be very effective in accessing highly positioned Kuhn type IV cells.

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.