Introduction
Pott’s puffy tumor is a rare complication of sinusitis that requires a high index of suspicion, as early detection and treatment are crucial. It has been described as frontal osteomyelitis associated with a subperiosteal abscess [1]. Its pathognomic symptoms include fever and a “doughy” erythematous forehead swelling [2]. It may occur as a hematogenous spread or direct extension of an infection. Pott’s puffy tumors can be complicated by intracranial extension through the diploic veins between the frontal sinus and dural venous plexus; therefore, brain imaging must be performed to exclude intracranial involvement, especially when neurological signs and symptoms exist [1,2]. The length and frequency of sinusitis complications have reduced due to the increased use of antibiotics, making Potts puffy tumor an uncommon condition. However, surgical intervention can improve outcomes with faster clearance of the infection [2]. Although Pott’s puffy tumor is an uncommon manifestation of sinusitis, it must be identified and treated to prevent serious intracranial complications. Herein, we present a rare case series of two patients with pansinusitis complicated by Pott’s puffy tumor, which was treated differently with good outcomes.
Case Presentation
Case 1
A previously healthy 9-year-old boy presented with a history of an upper respiratory tract infection (URTI) with fever accompanied by intermittent frontal headache for the past 5 days. Two days before the presentation, the mother noticed worsening swelling in the left upper eyebrow associated with photophobia, vomiting, and decreased activity and oral intake. She also noticed worsening swelling in the frontal region. There was a history of contact with a sick patient that had URTI. There was no history of trauma, gastroenterological or urological symptoms and abnormal movements. Moreover, his vaccination schedule was up to date.
Upon examination, he was lying in bed, looking well, and was not experiencing pain or distress. There was left periorbital swelling associated with swelling of the frontal region and tenderness (Fig. 1). The extraocular muscles were intact with no meningeal signs. Lymphadenopathy was not observed. The results of the otoscopic and neurological examinations were unremarkable. Additionally, chest and cardiovascular examinations revealed normal results.
His laboratory workup revealed leukocytosis with a white blood cell count of 18.1 × 103/mcl and high levels of inflammatory markers (C-Reactive Protein: 113.5 mg/l, and erythrocyte sedimentation rate (ESR): 107 mm Hg/hour). Blood cultures were obtained with no bacterial growth after 5 days.
A contrast-enhanced computed tomography (CT) of his brain and orbits (Fig. 2) showed left periorbital inflammation, and the left frontal scalp showed diffuse soft-tissue edema and enhancement. In addition, the frontal sinuses and bilateral anterior ethmoidal air cells were opaque, indicating bacterial sinusitis.
As the patient presented to the emergency department with fever and photophobia. A single intravenous dose of ceftriaxone and clindamycin was administered to the patient in the emergency department. The same antibiotics were continued in addition to decongestants and the patient was admitted to the general pediatrics department.
As the patient was admitted, he still displayed symptoms of fever and photophobia; therefore, infectious disease was consulted, consulted, and the antibiotics were upgraded to ceftriaxone, vancomycin, and metronidazole.
The patient presented to the emergency department with a fever and photophobia. He was given a single intravenous dose of ceftriaxone and clindamycin. He was admitted to the general pediatrics department and was treated with ceftriaxone, vancomycin, and metronidazole as well as decongestants.
Magnetic resonance imaging (MRI) of the sinuses, orbit, and brain was performed (Fig. 3), showing cranial fossa, bifrontal pachymeningeal, and frontal bone marrow enhancement with a small frontal extracranial subperiosteal abscess. There were no apparent intracranial collections, and the brain parenchyma was normal. An otolaryngologist was consulted, medical management was advised, and surgical intervention was not required.
On admission, the patient had a fever, with swelling of the frontal region and left periorbital regions.
The patient improved during this admission and was discharged with oral clindamycin and cefdinir for an additional 3 weeks after 14 days of intravenous antibiotics, with close follow-up appointments in the clinic. The patient was seen in the clinic 7 days after discharge and showed complete resolution of symptoms, clinical improvement and normalization of inflammatory markers and white blood cell count.
Case 2
A previously healthy 10-year-old girl presented with swelling of the right eye and forehead associated with headaches for 5 days, preceded by URTI and gastroenteritis symptoms for 2 weeks.
Figure 1.
Photographs of our patient (Case 1) upon presentation. (A) Frontal view showing left periorbital swelling and soft tissue swelling in the frontal region. (B) Lateral view taken from the patient’s left side, demonstrating swelling protruding from the frontal region.
Figure 2.
CT scan of the brain and orbits of our patient (Case 1). (A and B) Sagittal and axial view, respectively, showing diffuse soft tissue swelling and enhancement with fatty stranding, extending up to the frontal scalp. Additionally, the frontal sinuses and bilateral anterior ethmoidal air cells were opaque. (C) Axial view showing left periorbital inflammation.
Figure 3.
MRI of sinuses, orbits and brain. (A and B) Sagittal view and axial view, respectively, showing small frontal subcutaneous collection surrounded by significant soft tissue thickening and enhancement as well as diffuse mucosal thickening of all paranasal sinuses.
There was no history of fever, photophobia, decreased visual acuity, trauma, abnormal movement, insect bites, or allergies. There was no history of trauma, gastroenterological or urological symptoms and abnormal movements. Moreover, her vaccination schedule was up to date.
Upon examination, she looked well and was vitally stable with no pain or distress. Moreover, she had right periorbital and forehead swelling just above the right eye associated with tenderness to palpation (Fig. 4A). Her extraocular movements were intact, and no meningeal signs or lymph node enlargement were observed.
Her laboratory workup, including complete blood count, renal function, and inflammatory markers, was of no concern except for a mildly elevated ESR (107 mm/H). A contrast-enhanced CT of her brain and orbits (Fig. 5) showed right preseptal cellulitis and a right upper lid multiloculated abscess with sequelae of right frontal, ethmoidal, and maxillary sinusitis, and right frontal mucocele. There was also evidence of pansinusitis with evidence of dense intrasinus material. However, a very large preseptal abscess formation was seen, with superonasal early subperiosteal reactional thickening. There were no signs of venous sinus thrombosis, cavernous sinus thrombosis, or superior ophthalmic vein thrombosis.
Figure 4.
Photographs of our patient (Case 2) upon presentation and post-surgery. (A) Frontal view of the right periorbital swelling and soft tissue swelling in the frontal region. (B) On day 2 post-surgery, the soft tissue swelling in the frontal region had resolved.
A single intravenous dose of ceftriaxone and clindamycin was administered to the patient in the emergency department. The otorhinolaryngology department was consulted, and the patient was admitted under their care.
The patient was started on systemic antibiotics including Intravenous Ceftriaxone, Clindamycin, and surgical intervention was planned. The next day, the patient underwent incision and drainage of the right upper eyelid, right functional endoscopic sinus surgery and adenoidectomy. The findings during surgery included a right eyelid abscess, dehiscent lamina papyracea, grade 4 adenoids and inflamed sinuses with pus. Intraoperative cultures revealed moderate growth of conjunctival flora, with no organisms were identified. Two days postoperatively, the patient’s condition improved, and the swelling had resolved (Fig. 4B).
She was continued on systemic antibiotics until 7 days post-surgery, shifted to oral antibiotics for 4 weeks, and was discharged in good condition with regular follow-ups.
Discussion
Pott’s puffy tumor is a rare complication of direct trauma or frontal sinusitis [1]. It is described as forehead edema caused by osteomyelitis of the frontal bone associated with subperiosteal abscess. The term “tumor” refers to the visible swelling of the forehead rather than actual neoplasia. In both cases reported, there was no history of trauma prior to presentation. However, both of them were secondary to frontal sinusitis with different severity presentation and management approaches which makes our case series rare and noteworthy.
The diploic veins drain the frontal sinuses. These veins are characterized as valveless veins, and their configuration facilitates hematogenous spread to the bones and brain [3].
Intracranial complications include meningitis, brain abscesses, and cavernous sinus thrombosis [3]. Infection may also spread to the orbital or periorbital compartments, as in our cases.
Pott’s puffy tumors commonly develop in adolescents as aeration of the frontal sinus is completed in this age group, as in our two cases they are almost in the early adolescent age group [4]. However, the tumors can develop at any age, and some studies have reported Pott’s puffy tumors in younger age groups [4,5].
Infections are often polymicrobial; therefore, the recommended initial therapy is empirical treatment with antibiotics that cover gram-positive bacteria and anaerobes [5]. Surgery options will be offered depending on imaging findings, such as the location and severity of the disease [1].
In the second case, a right upper lid multiloculated abscess was discovered in a CT scan of the brain and orbits, necessitating surgical intervention using functional endoscopic sinus surgery, which involved an incision and drainage.
In a study by Maheshwar et al. [6], a rare case was reported in which a Pott’s puffy tumor developed as a complication of maxillary sinusitis, requiring surgical debridement with an incision, drainage of the frontal bone abscess, and insertion of gentamicin beads. Utilizing gentamicin beads in the treatment of osteomyelitis is widely recognized by orthopedic surgeons, with good outcomes [6].
Figure 5.
A CT scan of the brain and orbits of our patient (Case 2). (A and B) Sagittal and axial view, respectively, showing right preseptal cellulitis and right upper lid multiloculated abscess with sequelae of right frontal, ethmoidal, and maxillary sinusitis and right frontal mucocele. (C) Axial view showing right periorbital swelling with fluid collection and pansinusitis.
Osteomyelitis of the outer surface of the frontal sinus and any intracranial implications are usually identified through imaging studies, including high-resolution CT scans and brain MRI [5]. A study that examined 53 articles from the literature and analyzed intracranial involvement in pediatrics revealed that 72% of cases had intracranial involvement, and adolescents were more frequently implicated than younger age groups [7]. This could be explained by the completion of the pneumatization process of the sinuses in this age group.
The prognosis would depend on early recognition, management and identification of any intracranial complications as if left untreated can be lethal [1]. Following immediate and appropriate therapy as well as the use of an ideal diagnostic workup, both cases had favorable outcomes in follow-up visits.
Therefore, a high index of suspicion should be maintained, and imaging studies should be performed as soon as possible during the diagnostic process, as intracranial involvement is common and may be asymptomatic during the early presentation.
Conclusion
Although Pott’s puffy tumor is a rare complication of frontal sinusitis, clinicians should maintain a high index of suspicion, as an intracranial extension is common. Moreover, if discovered and managed early, there will be good outcomes. Empiric antibiotics should be administered early to cover the most common organisms implicated in this condition. Therefore, multidisciplinary teams are required to diagnose and treat this condition.
List of Abbreviations
CT: computed tomography; ESR: erythrocyte sedimentation rate; MRI: magnetic resonance imaging; URTI: upper respiratory tract infection.
Ethics approval and consent to participate
This study has been approved by the Institutional Research Ethics Committee at King Fahad Medical City, Riyadh Saudi Arabia. IRB 00010471.
Consent for publication
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Availability of data and materials
The data that support the findings of this study are available from the corresponding author but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of King Fahad Medical City.
Competing interests
None of the authors have any competing interests to declare.
Funding
Not applicable.
Authors’ contributions
Idea development and case report writing: Eman Alghaith. Drafting the manuscript: Eman Alghaith, Abdulaziz Alareefy, Shinas Nellicka. Final writing up and critical revision of paper: Yara Algoraini. Submission of the manuscript: Yara AlGoraini. All authors read and approved the final manuscript.
Acknowledgments
We would like to thank the parents for their support and help.
