A Pott's Puffy Tumor Associated with Epidural - Cutaneous Fistula and Epidural Abscess: Case Report

Pott's puffy tumor: A case report

Key Clinical Message

Pott's puffy tumor is a rare condition primarily occurring in the younger population. This report highlights the clinical suspicion and diagnosis of Pott's puffy tumor in those presenting with favorable presentations, especially adolescents.

Abstract

Pott's puffy tumor (PPT) is characterized as frontal bone subperiosteal abscess and osteomyelitis, a rare condition primarily occurring in adolescents following frontal sinusitis or head trauma. We present a case of atypical PPT in a 12-year-girl following an insect bite. The patient presented with painful forehead swelling for 4 weeks without any history of head trauma or signs of sinusitis. She had a history of a purulent pimple 2 months before presentation, following an insect bite. The primary diagnosis of PPT was made based on clinical and imaging findings. The patient was treated surgically and medically with intravenous antibiotics and had a satisfactory recovery upon the 6-month follow-up visit. This case highlights the differential diagnosis and thorough evaluation for PPT in a child with acute headache and forehead swelling, even without sinusitis symptoms.

Case report: Diagnosis and treatment of delayed epidural pyogenic abscess after brain tumor operation: a report of 5 cases and review of the literature

Objective

To explore the clinical manifestations and treatment of delayed epidural pyogenic abscess after brain tumor surgery.

Method

To retrospectively analyze the medical records of 5 patients with delayed epidural pyogenic abscess after brain tumor surgery in our hospital from January 2010 to December 2020, including clinical manifestations, laboratory results, imaging findings, treatment measures, prognosis, etc. The causes of epidural abscesses were analyzed, and the treatment methods and prognosis were evaluated.

Result

Among the 5 cases, there were 4 male and 1 female patient, aged 52-75 years. Three cases were gliomas and 2 cases were meningiomas. Four cases received postoperative radiotherapy, and 1 case had open frontal sinus during operation. None of the surgical incisions were infected. The time between the tumor surgery and the discovery of an epidural abscess was 1.5 to 24 months. All 5 patients had headaches, 1 case had a fever, and 2 cases had limb dysfunction. Three cases had elevated blood inflammatory markers. MRI- DWI showed restricted diffusion. All 5 patients underwent surgery, 4 patients had bone flap removed, and 1 patient had bone flap retained. Bacterial culture was positive in 3 cases and negative in 2 cases. All 5 cases were cured, followed up for 1.5-9 years, and no epidural abscess recurred.

Conclusion

The clinical manifestations and laboratory results of delayed epidural pyogenic abscess after brain tumor surgery are not specific, but MRI-DWI has specificity. Postoperative radiotherapy for brain tumors and intraoperative opening of the frontal sinus may be associated with delayed epidural pyogenic abscess. For patients with normal skin flap and no serious inflammation of the bone flap, clinicians can attempt to preserve the bone flap.

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.

The rare presentation of a frontal mucocele complicated by a Pott’s puffy tumor and an epidural-cutaneous fistula: illustrative case

BACKGROUND

Frontal mucoceles develop due to accumulation of mucoid secretions within the frontal sinuses. They can lead to serious consequences with further expansion and destruction of the surrounding bones or infection that might spread intracranially.

OBSERVATIONS

The authors present a case of a 37-year-old male with a frontal mucocele and the rare presentation of Pott’s puffy tumor and an epidural-cutaneous fistula, as well as a literature review of previously reported cases of epidural cutaneous fistula and sinocutaneous fistula, their predisposing factors, and their management.

LESSONS

A mucocele is a benign entity that can rarely present with potentially significant complications. Open surgery is required in patients who have frontal sinus posterior wall involvement, osteomyelitis, or intracranial involvement.

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 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.

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.