Pott puffy tumor: a rare complication of sinusitis.

Pott puffy tumor, a rare complication of sinusitis in adults, appears as a localized swelling over the frontal region or forehead. This swelling is due to a subperiosteal abscess resulting from osteomyelitis of the underlying frontal bone. This condition may be associated with an epidural purulent collection, subdural empyema, and intracerebral abscess. This entity is rare--even forgotten--since the advent of modern powerful antibiotics. A 27-year-old male was referred to ENT OPD with forehead swelling, fever and headache. The patient had mooth doughy swelling of the foreheadwith surrounding cellulitis and swelling spreading to the orbits as periorbital odema. On examination, patient had very poor oral hygiene with severe dental caries. CT with contrast conformed pansinusitis with erosion of frontal bone and abscess. An early recognition of this forgotten complication of sinusitis will help avoid severe neurological sequelae and increased morbidity and mortality.

A Pott puffy tumor is a circumscribed swelling on the forehead due to a subperiosteal abscess that results from osteomyelitis of the underlying frontal bone.1 A doughy erythematous swelling associated with fever is pathognomonic of this condition. There may be associated headache, purulent rhinorrhea, photophobia, and signs of raised intracranial tension in complicated cases.2 The condition is usually diagnosed on the basis of the history and the clinical findings. Radiology, especially a CT scan with contrast, is diagnostic. MRI should be considered as the gold standard for the diagnosis of intracranial complications. We present a case of swelling of the forehead that was successfully treated with antibiotics, nasal decongestants, and analgesics.

CASE

A 27-year-old male with a forehead swelling was referred from the surgical outpatient department. The patient complained of headache. He had a well-demarcated, tender, erythematous, smooth-surfaced, doughy swelling on the forehead, measuring 3.5×3.5 cm. The local temperature was raised. The overlying skin was mobile, but the swelling was fixed to underlying bone. There was associated periorbital edema and cellulitis surrounding the swelling (Figure 1).

Figure 1

Frontal view of the patient.

On examination, oral hygiene was found to be poor with severe dental caries of the upper jaw. The temperature was 39.5°C. There was no nasal discharge or history of postnasal drip. A CT scan with contrast of the frontal bone, nose, and paranasal sinuses showed haziness of all sinuses, with a hypodense collection of fluid external to the frontal bone and enhancement of the rim; the appearance was suggestive of a Pott puffy tumor (Figures 2A, B). The patient was admitted and put on intravenous broad-spectrum antibiotics, nasal decongestants, and analgesics. The antibiotic choice was guided by the need to cover Staphylococcus aureus, nonenterococcal streptococci, and oral anaerobes. MRI was advised to rule out any intracranial involvement. Follow-up imaging studies after 4 weeks of antibiotic therapy showed resolution of the opacification of all sinuses and a decrease in the size of the subcutaneous swelling over the frontal bone. The intravenous antibiotic treatment was continued for 6 weeks and the patient recovered fully without sequelae.

Figure 2A

CT scan showing pansinusitis.

Figure 2B

CT scan showing erosion of frontal bone.

DISCUSSION

A Pott puffy tumor is defined as a circumscribed swelling of the forehead indicating an underlying osteitis of the skull or an extradural abscess. It was first described by Sir Percival Pott as a complication of forehead trauma in 1768 and in relation to sinusitis in 1775.3 It is most commonly due to osteomyelitis of the underlying frontal bone, which may be the result of trauma or infection such as acute/chronic sinusitis. When not treated promptly, osteomyelitis of the frontal bone and the resulting subperiosteal abscess gives rise to the characteristic Pott puffy tumor.

A Pott puffy tumor is a rare entity that is generally seen in older children and only very rarely in adults; however, there have been isolated reports of cases in adults.3–5 A Pott puffy tumor can be associated with subdural empyema, brain abscess, cortical vein thrombosis, and epidural abscess. Because the frontal sinus communicates through the diploic veins with the dural venous plexuses, intracranial involvement is possible, with or without direct erosion of the frontal bone.6,7 The organisms most commonly involved are S aureus, nonenterococcal streptococci, and oral anaerobes.8 A high index of suspicion is necessary to diagnose this rare condition. When diagnosed, the patient must be admitted and put on broad-spectrum intravenous antibiotics and analgesics. A CT scan with contrast and MRI should be done to confirm the diagnosis and rule out intracranial complications. Depending on the radiological findings, surgical intervention may be necessary for removal of osteomyelitic bone along with frontal trephination or endoscopic frontal sinusotomy. Neurosurgical consultation is required in case of intracranial involvement.

In conclusion, a Pott puffy tumor, although very rare in this modern era of antibiotics, may still occasionally be seen. When diagnosed, it should be treated promptly with broad-spectrum intravenous antibiotics for 4 to 6 weeks; surgical intervention may also be necessary, depending on the radiological findings. Prompt diagnosis and proper treatment will decrease the morbidity and mortality associated with this rare condition.