Although first described in 1760, Pott’s puffy tumor is a lesser known clinical entity. Often seen as a complication of frontal sinusitis, Pott’s is a frontal bone osteomyelitis with an associated subperiosteal abscess. Patients present with a fluctuant swelling of the scalp. The diagnosis is often confirmed with computed tomography (CT). Prompt surgical and medical treatments are the rule as there is the potential for significant morbidity if not quickly diagnosed and treated. Herein, we describe the presentation, diagnosis, and treatment of an 8-year-old female presenting with Pott’s puffy tumor.
Sir Percival Pott first described the phenomenon of a Pott’s puffy tumor as frontal swelling with a subperiosteal abscess and extradural empyema in 1775 [
An 8-year-old female, with no significant past medical history, presented with swelling of her forehead and a low-grade fever. She had been in her usual state of health until 12 days prior to admission when she developed a fever (temperature: 38.8°C), headaches, nasal congestion, and a decreased energy level. She was observed and treated symptomatically. Eight days prior to admission, her fever persisted, and she developed swelling of the forehead which was more prominent in the glabellar area. She was started on Cefdinir 250 mg once daily (8 mg/kg/day) for the management of a presumed facial cellulitis. In addition, she was prescribed a nasal decongestant and systemic antihistamine therapy. Her headache and fever resolved; however, the swelling of the forehead progressed. Moreover, generalized swelling of the eyelids, cheeks, and face became obvious. She was admitted for further workup and management.
Physical examination on admission showed a well-nourished female in no acute distress. Her vital signs were unremarkable except for a temperature of 38.6°C. Her weight was at the 75th percentile (31.3 kg) and height was at the 50th percentile (133 cm). She answered questions appropriately and was cooperative with the examination. There was a pronounced, erythematous swelling of the forehead and edema of the eyelids (Figure
Sagittal view at the time of presentation demonstrating a notable amount of fullness over the area corresponding to the frontal sinus.
Laboratory evaluations on the day of admission revealed the following: hemoglobin: 11.9 g/dL (reference range from, 11.5 to 15.5 g/dL); leukocytes: 17980/mm³ (reference range, 5000–15500/mm³) with absolute neutrophil count 13760/mm³ (reference range, 1500–9000/mm³); platelets: 411,000/mm³ (reference range, 150000–350000/mm³); erythrocyte sedimentation rate (ESR): 98 mm/hr (reference range, 0–20 mm/hr).
Computerized axial tomography scans of the head and sinuses (Figures
Axial CT of the brain demonstrating subperiosteal (arrow) and epidural abscesses (circle).
Axial CT without contrast on presentation demonstrating erosion of the anterior and posterior tables of the frontal sinus (arrows), frontal sinus opacification (arrowhead), and soft tissue swelling of the forehead.
After obtaining two blood cultures and a nasopharyngeal swab for bacterial cultures, the patient was started on high-dose intravenous antibiotic therapy with vancomycin, cefotaxime, and metronidazole. The otolaryngology and neurosurgery services were consulted, and surgical intervention was deemed necessary based on clinical exam and imaging studies. The following day she went to the operating room in a combined operation with otolaryngology and neurosurgery to address the forehead abscess, epidural abscess, and the underlying frontal sinus disease. An incision was made posterior to the hairline in the frontal region to approach the forehead abscess. This was incised, and 100 mL of frankly purulent fluid were expressed. A burr hole was created in the right frontal region, and again purulent fluid was identified. The epidural space was irrigated and suctioned. The dura was intact. Surgical drains were placed at the sites of the drained forehead and intracranial abscesses. To address the sinus disease, we utilized image guidance to create a left nasal antral window, bilateral frontal sinusotomies, anterior ethmoidectomies, and uncinectomies. Purulent fluid was obtained from the left middle meatus, left maxillary sinus, and left ethmoid bulla. Specimens were sent for gram stain, aerobic, anaerobic, fungal, and acid-fast cultures.
Gram stain of the subgaleal and epidural purulent fluid showed many neutrophils, moderate gram-positive cocci in chains, and a few gram negative bacilli. Routine culture of both specimens grew
Our patient responded remarkably well to therapy and was afebrile on postoperative day 1. There was a small amount of reaccumulation of subgaleal fluid which was aspirated on two occasions and cultures remained negative. She was discharged home on intravenous Ampicillin/sulbactam through a peripherally inserted central catheter (PICC) and followed up in clinic. She continued to make progressive improvement. Twenty days into therapy, she developed a progressive, erythematous rash with itching unresponsive to diphenhydramine. In view of this development, antibiotic therapy was switched to intravenous meropenem via a peripheral inserted central catheter (PICC) in every 8-hour dosing. Her ESR remained stable at 27 mm/hr, and C-reactive protein had come down to 0.1 mg/dL. After 45 days of antibiotics, therapy was discontinued. She has continued to do well 2 years after therapy.
In 1760, Sir Percival Pott first described Pott’s puffy tumor as “a puffy, circumscribed, indolent tumour of the scalp and a spontaneous separation of the pericranium from the skull under such a tumour” [
Knowledge of the anatomy and embryology of the frontal sinus is critical in understanding the intracranial pathogenesis of Pott’s tumor. The frontal sinuses develop from the ethmoid air cells and approach adult size between 12-13 years old [
Most commonly in Pott’s puffy tumor, an untreated frontal sinusitis leads to an osteomyelitis of the anterior table of the frontal sinus and subperiosteal abscess formation. The anterior table of the frontal sinus is thinner than the posterior table and is more susceptible to abscess formation [
Although rare, given the potential for significant morbidity, a high index of suspicion for Pott’s puffy tumor is required in patients presenting with fluctuant, tender, erythematous swelling of the scalp. Presentation can include headache, vomiting, fever, seizures, periorbital or scalp swelling, nasal or aural discharge, or focal deficits [
CT of the brain is a diagnostic study of choice. It identifies intracranial and extracranial complications associated with frontal sinusitis [
Sagittal MRI demonstrating an abscess within the frontal scalp (arrow) and an adjacent epidural abscess (circle).
Pott’s puffy tumor is a surgical emergency. With the advent of modern functional endoscopic sinus surgery, this treatment can often be performed minimally invasively. In this case, treatment by both the otolaryngology and neurosurgery services was needed to address the concomitant sinus and intracranial disease. Frankly, diseased bone and granulation tissue require removal. Moreover, patency of the frontonasal duct must be reestablished [
Sinus cultures obtained intraoperatively are often polymicrobial. Organisms responsible for this disease process include alpha and beta hemolytic
Although initially described by Pott as a complication of trauma, this disease process is most frequent due to frontal sinusitis. As in this case, a high index of suspicion, accurate diagnosis, and prompt treatment are critical in achieving an optimal outcome.
The authors would like to thank Ms. Charlotte McPeek for her generous assistance in editing and preparation of this paper.