International Journal of Pediatric Otorhinolaryngology Extra
Volume 2, Issue 4 , Pages 215-217, December 2007

An 11-year-old girl with Pott's puffy tumour

Duzce University, School of Medicine, Department of Neurosurgery, Konuralp, 81620 Duzce, Turkey

Received 19 April 2007; received in revised form 5 June 2007; accepted 10 June 2007.

Article Outline

Summary 

Objective: Pott's puffy tumour (PPT) is a rare entity that is characterised by a subperiosteal abscess associated with frontal bone osteomyelitis. Case: We report a case where a frontal periosteal abscess was successfully treated with simple surgical abscess drainage, followed by prolonged broad-spectrum antibiotic therapy. Conclusion: The treatment goal is early diagnosis and aggressive therapy to prevent severe complications like meningitis, subdural empyema, and brain abscess.

Keywords: Complication, Epidural abscess, Frontal osteomyelitis, Pediatric neurosurgery, Pott puffy tumour, Scalp abscess

 

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1. Introduction 

Pott's puffy tumour (PPT) is defined as a subperiosteal abscess of the frontal bone associated with underlying osteomyelitis [1]. It appears as a localised swelling of the forehead. Symptoms associated with PTT are headache, periorbital oedema, fever, vomiting, rhinorrhoea, and lethargy [2], [3].

Pott's puffy tumour occurs most frequently in teenagers [2], [4]. Although rare, it is associated with a high risk of meningitis, abscess, and venous sinus thrombosis. Early diagnosis and treatment are essential to prevent these severe complications [5], [6]. This article presents an unusual case of an 11-year-old girl with PPT.

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2. Case report 

An 11-year-old girl was admitted through the Emergency Department (ED) with a soft mass on her vertex. She had been referred to the ED with periorbital swelling 2 days earlier. Then, she had been diagnosed with angioneurotic oedema and sent home after medical therapy had been scheduled. When she developed a soft, fluctuant swelling with pain on the vertex, she returned to the ED and consulted us. In her medical history, there was no trauma, fever, or disease, including immunosuppression. On physical examination, a 3cm×3cm×2cm tender, fluctuant scalp swelling on the vertex was noted. Her neurological examination was normal. Laboratory blood values showed a white cell count of 16,200mm−3 (normal 5200–12,400mm−3), C-reactive protein of 4.89mg/dL (normal 0–1.1mg/dL), an erythrocyte sedimentation rate of 94mm/h (normal 0–10mm/h), a haemoglobin of 10.1g/dL (normal 12–18g/dL), and a platelet count of 389×109L−1 (normal 130×109–400×109L−1). Cranial X-ray showed an irregularity at the vertex. Computerised tomography (CT) revealed a 4cm×5cm subperiosteal abscess and epidural abscess collection that had eroded the vertical frontal bone (Fig. 1a and b). The patient was consulted with ear-nose and throat (ENT) Department. Although her paranasal sinus CT revealed frontal, maxillary and sphenoidal sinusitis the ENT examination was normal.

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  • Fig. 1. 

    (a) Computerised tomography (CT), showing a 4cm×5cm subperiosteal abscess and epidural abscess collection. (b) Computerised tomography (CT), showing destruction of the vertical frontal bone.

She underwent emergency surgery. After making a 5-cm horizontal incision over the vertical galea, the subperiosteal abscess was drained, and samples were taken for culture and Gram staining. The abscess pouches were removed. Since the abscess had a bad odour, the wound was irrigated with antibiotic solution and hydrogen peroxide. The patient was treated with simple surgical abscess drainage using a Penrose drain for 5 days, followed by 8 weeks of broad-spectrum antimicrobial coverage with ampicillin, ceftriaxone, and metronidazole. The abscess culture revealed Gram-positive (Peptostreptococcus) and Gram-negative (Veilonella) anaerobic diplococci, and Gram-negative bacilli (E. coli). The neurological examination and follow-up CT 3 months later were normal.

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3. Discussion 

Pott first described Pott's puffy tumour in 1760 [7]. From an epidemiological perspective, since the frontal sinuses become pneumatised at 6 years of age, and they reach their adult configuration at the age of 15, teenagers are especially prone to this disease [8]. Kaplan suggested that adolescence is associated with a peak in the vascularity of the diploic circulation, which makes adolescents vulnerable to PTT after sinusitis [9].

Pott's puffy tumour usually follows sinusitis. Frontal sinus infection causes osteomyelitis and subperiosteal and epidural abscesses. In addition, the infection can spread to the subdural space, causing subdural collection and cerebritis [2], [10]. Hematogenous dissemination causes sinus thrombosis, subdural empyema, and brain abscess [3], [11]. Although the vast majority of cases have acute or subacute presentations, there is a case report of PPT developing approximately 14 years after head trauma [12]. Gupta et al. have emphasised that PPT is very rare in pre-teenage children [13]. Although ENT consultation was normal, cranial CT revealed frontal, maxillary and sphenoidal sinusitis in the present case.

The most commonly encountered organisms are Streptococcus, Staphylococcus, and anaerobic species. Patients with PPT usually have a polymicrobial infection. However, when intracranial complications occur, anaerobic pathogens predominate [3], [14].

The symptoms of patients with PPT include scalp or periorbital swelling, purulent or non-purulent rhinorrhea, headache, and fever [15], [16], [17]. A tender, fluctuant erythematous swelling of the scalp at the mid-forehead is typical.

The treatment of patients with PPT includes the administration of broad-spectrum antibiotics (at least 6–8 weeks intravenously) and evacuation of infected areas, including any subperiosteal abscess, osteomyelitic bone, and epidural granular tissue. Before the antibiotic era, frontal osteomyelitis had a high mortality rate. Bordley and Bischofberger [18] reported that the mortality rate for frontal osteomyelitis was 60%. By contrast, in 1984, Bradley et al. [19] reported that the mortality rate in subdural and frontal lobe abscess secondary to paranasal sinusitis was 25%, and in 1989, Remmler and Boles [20] reported a mortality rate of approximately 30% in patients with subdural empyema.

In conclusion, we have reported a case of a PPT treated with minimally invasive surgical intervention and antibiotic therapy. We would like to emphasise the importance of early diagnosis of PPT and aggressive therapy to prevent severe complications (meningitis, subdural empyema, and brain abscess).

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References 

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PII: S1871-4048(07)00050-0

doi:10.1016/j.pedex.2007.06.002

International Journal of Pediatric Otorhinolaryngology Extra
Volume 2, Issue 4 , Pages 215-217, December 2007

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