International Journal of Pediatric Otorhinolaryngology Extra
Volume 7, Issue 1 , Pages 1-5, January 2012

Pott's puffy tumor in a 5-year-old boy: The role of ultrasound and contrast-enhanced CT imaging—Surgical case report

  • O.M. Vanderveken

      Affiliations

    • Department of Otorhinolaryngology, Head and Neck Surgery, Queen Paola Children's Hospital, ZNA Middelheim, Antwerp, Belgium
    • Faculty of Medicine, University of Antwerp, Belgium
    • Corresponding Author InformationCorresponding author at: University Department of Otorhinolaryngology, Head and Neck Surgery, Faculty of Medicine, University of Antwerp, p/a Wilrijkstraat 10, BE-2650 Edegem (Antwerp), Belgium. Tel.: +32 38213384.
    • ,
  • K. De Smet

      Affiliations

    • Department of Radiology, Queen Paola Children's Hospital, ZNA Middelheim, Antwerp, Belgium
    • ,
  • S. Dogan-Duyar

      Affiliations

    • Department of Pediatric Intensive Care, Queen Paola Children's Hospital, ZNA Middelheim, Antwerp, Belgium
    • ,
  • J. Desimpelaere

      Affiliations

    • Department of Radiology, Queen Paola Children's Hospital, ZNA Middelheim, Antwerp, Belgium
    • ,
  • E.L.I.M. Duval

      Affiliations

    • Department of Pediatric Intensive Care, Queen Paola Children's Hospital, ZNA Middelheim, Antwerp, Belgium
    • ,
  • M. De Praeter

      Affiliations

    • Department of Neurosurgery, Queen Paola Children's Hospital, ZNA Middelheim, Antwerp, Belgium
    • ,
  • D. Van Rompaey

      Affiliations

    • Department of Otorhinolaryngology, Head and Neck Surgery, Queen Paola Children's Hospital, ZNA Middelheim, Antwerp, Belgium

Received 2 August 2010; accepted 12 August 2010. published online 28 October 2011.

Article Outline

Abstract 

We report the case of a Pott's puffy tumor, a subperiosteal abscess of the frontal bone associated with an underlying frontal osteomyelitis, in a 5-year-old boy. Pott's puffy tumor is a complicated infection that requires adequate treatment consisting of prompt surgical management and strict antibiotic therapy. Early diagnosis is critical to prevent severe complications and sequelae. In our patient ultrasonography played a crucial role in the diagnosis, suggesting the presence of a Pott's puffy tumor with epidural abscess by showing a subperiosteal abscess associated with erosion of the frontal bone. Subsequently, the diagnosis of Pott's puffy tumor with epidural abscess was confirmed by contrast-enhanced CT scan. Prompt surgical intervention with drainage of abscesses and debridement of bone sequestrate, together with prolonged antibiotic therapy, significantly contributes to favorable outcomes.

Keywords: Epidural abscess, Frontal sinusitis, Osteomyelitis, Percival Pott, Puffy tumor, Surgery

 

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1. Introduction 

“Pott's puffy tumor” (PPT) is a rare clinical entity in the modern era of antibiotics [1], [2], [3]. PPT refers to one or more subperiosteal abscesses of the frontal bone, typically characterized by frontal osteitis and osteomyelitis [3], [4], [5], [6], [7], [8], [9], [10]. While this condition generally results from acute frontal sinusitis, other etiologic factors have been proposed [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22]. Although it can affect all ages, PPT is predominantly found among adolescents [10], [17], [23]. Early diagnosis of PPT using thorough radiological evaluation is of high importance in order to avoid intracranial and extracranial complications [6], [17], [20], [24]. An appropriate treatment combines antimicrobials and surgery [17].

We report a 5-year-old boy who developed PPT complicated by an epidural abscess. The literature is reviewed and pathogenesis, diagnosis and management are discussed.

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2. Case report 

A 5-year-old boy presented with an expanding left-sided swelling of the forehead (Fig. 1). The fluctuant, nontender swelling occurred 2 weeks before admission. In another hospital, following a tentative diagnosis of sinusitis, oral antibiotics were given. As a result of persistent swelling, the patient was referred to our hospital.

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  • Fig. 1. 

    Preoperative photographs of the 5-year-old boy referred to our children's hospital. The patient presented with a “Pott's puffy tumor”, showing an extensive frontal scalp swelling. Lateral view (left). Frontal view (right).

At the time of admission to our children's hospital, there was no history of trauma and the patient was afebrile. Clinical examination was inconclusive upon admission. Laboratory tests yielded the following results: Hgb 11g/dL, white blood cell count (WBC) 12,500×109L−1, erythrocyte sedimentation rate (ESR) 92mm/h, C-reactive protein <0.1mg/dL.

Ultrasound examination of the frontal swelling was suggestive for a subperiosteal abscess with discontinuity of the frontal bone (Fig. 2).

Subsequently, a contrast-enhanced CT scan was performed in order to exclude intracerebral extension. The presence of a frontal sinusitis complicated by osteomyelitis of the frontal bone and by a subperiosteal (24mm×16mm×6mm, LL×CC×AP) and an epidural abscess (21mm×38mm×7mm, LL×CC×AP) was confirmed (Fig. 3). Three-dimensional (3D) reconstruction of multislice CT data set was performed and demonstrated an osseous defect of the frontal bone (Fig. 4, external view: upper right panel; internal view: lower right panel).

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  • Fig. 3. 

    Contrast-enhanced multislice CT scan confirmed the presence of a frontal sinusitis with osteomyelitis of the frontal bone (↑) and with subperiosteal (*) and epidural (**) abscess measuring 24mm×6mm×6mm and 21mm×38mm×7mm. Brain window (left). Bone window (right).

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  • Fig. 4. 

    The osteomyelitic focus: surgical view (upper left panel): 3D-CT reconstruction, external view (upper right panel); axial CT image, bone window (lower left panel); 3D-CT reconstruction, internal view (lower right panel).

The patient was diagnosed with “Pott's puffy tumor” (PPT) and a left-sided epidural abscess. This rare entity is considered as a complication of bacterial frontal sinusitis. The patient was admitted to hospital and was started on intravenous antibiotics (amoxicillin and clavulanic acid). Neurosurgery performed a craniotomy using a bicoronal approach with surgical drainage of the epidural abscess. A thorough surgical debridement of the osteomyelitic focus was performed (Fig. 4). Subsequently, the frontal sinus was opened and debrided (Fig. 5). The defects were reconstructed successfully with a temporalis muscle flap.

Before transferral to the ward, the patient spent the first 24h after surgery in a pediatric intensive care unit. The obtained cultures of swabbed contents from the frontal sinus and epidural space remained sterile. Post-operative course was uneventful and the boy was discharged home on the 5th post-operative day with continuation of the antibiotic regimen (amoxicillin/clavulanic acid). The patient had a complete and excellent recovery without any cosmetic or neurological sequelae. In 1 year of follow-up, there was no recurrence.

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3. Discussion 

“Pott's puffy tumor” (PPT) was first described by Sir Percival Pott in 1760 as a complication of trauma to the frontal bone, but it is more commonly observed as a complication of frontal sinusitis spreading to the frontal bone [12], [13], [15], [25]. PTT has also been reported as a result of dental sepsis, or as a complication of intranasal cocaine abuse [14], [16]. Other reports include PPT occurring after acupuncture therapy and PPT caused by an insect bite [18], [19], [21]. Another risk factor includes PTT as a delayed complication after surgery [9].

Epidural abscesses, subdural empyema, brain abscesses and cortical vein thromboses are possible complications associated with PPT [26], [27], [28]. As a consequence, PPT presents a diagnostic challenge with a need for early recognition [29]. Early diagnosis is based on clinical examination, and appropriate imaging, and is critical to prevent complications [2], [8].

Few cases only have been reported in the post-antibiotic era. PTT is described as a frontal bone osteomyelitis resulting in a subperiosteal collection presenting as a fluctuant mass over the forehead [30]. The infection may spread as a thrombophlebitis from the frontal sinus through the diploic veins, involving the intracranial space with consequent epidural or subdural empyema, meningitis, frontal lobe abscess, and cavernous sinus thrombosis [8], [25], [27]. Direct extension of the infection occurs when there is a history of trauma or malignancy [17], [24], [31]. Subperiosteal abscess results from extension through the anterior wall [17], [24].

The vast majority of reported cases of PPT occurred in adolescents and adults. As the frontal sinuses complete their progressive pneumatization and development at preteen age, infections would not appear until later childhood [8], [10], [31], [32]. Therefore, the occurrence of PPT in pre-adolescent children is rare and fewer than fifteen other cases of Pott's puffy tumors have been reported under age 12 in the post-antibiotic era [9], [10], [21], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42], [43]. To the authors’ knowledge, only three cases have been reported of Pott's puffy tumor in children younger than 6 years of age in the English-language literature [10], [34], [35]. This is apart from a case that has been described recently by Chang et al. with the diagnosis of PPT with both orbital and intracranial extension in a premature infant with MRSA infection [44].

Most of the cultured organisms consist of anaerobic pathogens, while viridans streptococci and staphylococci are rare pathogens [3], [5], [7], [10], [11], [26], [27], [31]. In the reported patient, culture remained negative probably due to previous antibiotic treatment.

A high index of suspicion based on the history and clinical examination is necessary to identify this complication. This rare but grave condition is easily confused with neoplasms, skin and soft-tissue infection, and infected hematoma [23]. Apart from headache and frontal swelling, the clinical presentation and laboratory investigations may be inconclusive [4], [37].

Radiologic examination of the brain is mandatory [4], [17]. The diagnosis of PPT can be presumed by ultrasonography and, subsequently, the sonographic findings can be confirmed by CT scan [6], [37]. Contrast-enhanced CT scan is regarded as the most adequate study to confirm the diagnosis, although magnetic resonance imaging (MRI), technetium-99m scan, ad gallium-67 scanning have been reported as supportive investigations [5], [17], [24], [42], [45]. For the determination of osteomyelitis, however, contrast-enhanced CT is preferred, as CT scan is superior to MRI in its superior depiction of bony detail [11], [17], [24]. Typical characteristics of PPT on CT scan are opacification of frontal sinus with underlying destruction of the frontal bone and pericranial fluid collection [3], [17].

In our patient ultrasound played a crucial role in the diagnosis, suggesting the presence of PPT by showing a subperiosteal abscess associated with erosion of the frontal bone (Fig. 2). This imaging finding should be considered as a red flag and asks for further contrast-enhanced CT, in order to evaluate for the presence of intracranial complications as well as to confirm the diagnosis [8], [11], [24], [46].

The frontal bone infection and necrosis, commonly associated with intracranial complications, mandate quick management [4], [15]. Early intervention corresponds with favorable outcomes in even the more affected patients [17], [27], [31]. Surgical treatment options include functional endoscopic sinus surgery and/or an open neurosurgical approach through a standard bicoronal skin incision including craniotomy, with opening of the affected frontal sinus [5], [6], [21], [22], [36], [37], [38], [47].

In addition to prompt surgical intervention with drainage of abscesses and debridement of bone sequestrate, intravenous antibiotics must be initiated early and continued for sufficient time [4]. Despite surgical management and antimicrobial therapy, the mortality rate is 5–17% [8], [21], [48].

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4. Conclusion 

This case illustrates that “Pott's puffy tumor” is an infrequent clinical entity with a varied etiology and a vague presentation [6], [7], [8], [10], [11]. PPT remains an unusual, but important and serious complication of frontal sinusitis [36], [38]. When a patient presents with a fluctuant and indolent swelling of the forehead, a high degree of suspicion is needed by the clinician and immediate radio-imaging is mandatory to evaluate the possible complications [4], [5]. Early diagnosis is of utmost importance in order to effectuate a proper therapeutic approach [17], [29]. We emphasize on the role of ultrasound contributing to the early diagnosis of Pott's puffy tumor as the presence of PPT can be presumed by ultrasonography [6], [37]. Ultrasonography can be very helpful in distinguishing between soft-tissue abscess, superficial cellulitis, and subperiosteal abscess [37]. Subsequently, the diagnosis can be confirmed by contrast-enhanced CT scan [7], [37]. Treatment requires joint medical and surgical care, with prompt drainage of the sinus and removal of the sequestrum, along with long-term use of antibiotics [7].

Once the diagnosis of PPT is suspected, early diagnosis with appropriate imaging, together along with prompt surgical treatment and the use of appropriate antibiotics, is necessary in order to avoid more severe complications, such as subdural empyema, and secondary septic thrombosis of the dural sinuses [4], [5], [7], [15], [31], [36]. Even in the presence of such complications, early surgical intervention and administration of intravenous antibiotics will most likely lead to a favorable outcome with avoidance of severe neurological complications and sequelae [4], [7], [17], [31], [42].

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PII: S1871-4048(10)00057-2

doi:10.1016/j.pedex.2010.08.002

International Journal of Pediatric Otorhinolaryngology Extra
Volume 7, Issue 1 , Pages 1-5, January 2012

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