- Email: [email protected]
Cutaneous fistula is a rare presentation of Pott's puffy tumour
1246
Correspondence and communications
Figure 2
Close-up view of BCC.
for all age groups, significantly 50e64s and 65e79s. However the largest average increase in incidence was noted in the 30e39s, though this fell short of statistical significance at the 5% level. Population-based studies have extrapolated current data to predict an almost exponential increase in BCC in the future, primarily in younger females.1 These observations suggest an alarming rise in the presentation of these cancers at younger ages and it is important to both raise awareness of this trend and to maintain a high index of suspicion in all age groups, even teenagers.
References 1. De Vries E, van de Poll-Franse LV, Louwman WJ, et al. Predictions of skin cancer incidence in the Netherlands up to 2015. Br J Dermatol 2005;152:481e8. 2. Christenson LJ, Borrowman TA, Vachon CM, et al. Incidence of basal cell and squamous cell carcinomas in a population younger than 40 years. JAMA 2005;294:681e90. 3. Bath-Hextall F, Leonardi-Bee J, Smith C, et al. Trends in incidence of skin basal cell carcinoma. Additional evidence from a UK primary care database study. Int J Cancer 2007;121:2105e8.
Helen E. Douglas Reena Agarwal David G.K. Lam Department of Plastic Surgery, Sorby 2, Northern General Hospital, Sheffield S5 7AU, United Kingdom E-mail address: [email protected] ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2007.12.065
Response to: ‘Malignant melanoma re-excision specimens: is there a need for histopathological analysis?’ McGoldrick et al., J PRAS 2008; 61:983e984 The paper from McGoldrick et al.1 reinforces the conventional view that it is unnecessary to examine re-excision
specimens from melanoma by extensive histological sampling where previous excision is complete. This will be welcome news to histopathologists, and also to laboratory managers struggling with their budgets. Those centres, and they do exist, where acres of unremarkable skin are routinely processed from re-excision specimens would do well to take note. As the authors correctly indicate, there may be other areas where resources could be more effectively diverted. However, the authors’ conclusions are radical. I wonder how many clinical units would be happy to have no histology at all? Current national recommendations, not always followed, suggest one block is sufficient. This does at least confirm a scar is present. I have personally encountered palmar, plantar and genital ‘re-excisions’ where histology showed this was not the case. Others may have had similar experiences. There are further considerations. Will all pathologists be happy to accept a surgical decision on the absence of macroscopically visible lesions? Who is going to independently assess the adequacy of the surgeon’s excision margin? Do all clinical teams have confidence in the quality of information relating to the completeness of previous excisions, especially where such information has been provided by another unit? The authors accept that there may be special circumstances where histology is needed. I suspect many other units will not ‘feel comfortable’ about consigning the remainder of their re-excisions to the waste disposer.
Reference 1. McGoldrick RB, Ng D, Sawyer A, et al. Malignant melanoma re-excision specimens: is there a need for histopathological analysis? J Plast Reconstr Aesthet Surg 2008;61:983e4.
Andrew Boon St James’s University Hospital, Leeds, UK E-mail address: [email protected] ª 2008 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. doi:10.1016/j.bjps.2007.10.058
Cutaneous fistula is a rare presentation of Pott’s puffy tumour Pott’s puffy tumour is a soft tissue swelling overlying osteomyelitis of the frontal bone rarely observed in postantibiotic clinical practice.1 This sub-periosteal abscess is usually secondary to frontal osteomyelitis caused by chronic paranasal sinusitis; it can be less frequently generated by skull traumas and diseases or fronto-nasal iatrogenic procedures. Streptococci, staphylococci or anaerobes are the most common offending microorganisms, with Haemophilus influenzae and fungi being the causative agents in exceptional cases. Possible complications are cutaneous fistulas,
Correspondence and communications
1247
neurological emergencies (meningitis, subdural, epidural or intracerebral abscesses, sagittal sinus thrombosis) and systemic sepsis. Diagnosis is often unfamiliar and late so that potentially life-threatening complications can develop. Multidisciplinary surgical intervention is commonly recommended and it can be more or less complicated in accordance with involved anatomical sites. This case report stresses the necessity of recognizing this rare soft tissue condition, avoiding misdiagnoses responsible for possible fatal consequences.
Case report A 55-year-old woman presented to our department with a 2-month history of a mid-forehead localized and illdefined non fluctuating swelling (Figure 1), accompanied with slight local pain and headache, which had been discharging purulence intermittently through a small cutaneous fistula for a few days. No systemic symptoms were present and laboratory tests were normal. In other departments this lesion had been mistaken for an inflamed epidermoid cyst and treated unsuccessfully with oral antibiotics and local lavage of the wound for a total period of 3e4 weeks. Eight years earlier she had undergone posttraumatic right frontal craniotomy and cranial osteoplastic reconstructive surgery by acrylic resins. During the first surgery the opening of the frontal sinus was required for the total exposure of the traumatic frontal lesion. She had no prior history of sinusitis and no sign of nasal discharge or ocular disturbances. The patient was otherwise healthy. Computerised tomography (CT) and magnetic resonance imaging (MRI) with gadolinium revealed frontal cellulitis and osteomyelitis extending to the right sinus and giving rise to a sinus-cutaneous fistula where there were evident radiological signs of past cranioplasty; subdural space involvement was excluded (Figure 2A). From a swab of the cutaneous discharge Staphylococcus aureus was isolated. The patient was subjected to aggressive surgery which consisted of the excision of the fistula tract, radical removal of the nonviable material, curettage of the
Figure 2 (A) Preoperative CT scan (bone window) shows soft tissue swelling overlying osteomyelitis of the frontal bone associated with right frontal sinusitis. The right frontal craniotomy was performed for a traumatic lesion. Poly-methylmetacrylate was used to cover the post-surgical defect in the midline of the forehead. (B) Postoperative CT scan (3D) shows the results of the cranial osteoplastic reconstructive surgery. After the removal of the right frontal bone and debridement of the infected tissue, the left frontal craniotomy was performed and bone flap split to achieve a complete covering of the exposed dura. The mucosa of the frontal sinus was pulled out and the posterior wall was removed.
osteomyelitic bone and reconstructive cranial osteoplasty by split autologous bone of the outer frontal table after obliterating sinus (Figure 2B). Postoperative culturespecific systemic antibiotics were administered for 8 weeks. Cosmetic and functional results have been satisfactory and no relapse or sequela have been observed after 2 years.
Discussion
Figure 1 Clinical appearance of frontal localized swelling discharging through a small cutaneous fistula surrounded by granulation tissue.
Pott’s puffy tumour is an uncommon but well recognized entity among otolaryngologists, neurosurgeons and plastic and reconstructive surgeons, rarely reported with references to its cutaneous presentation. The most frequent cause of this frontal cellulitis is represented by frontal osteomyelitis secondary to chronic sinusitis, especially in children. It occurs as a result of the infection spreading, i.e. direct extension from the sinus to the overlying bone or less probably through diploic venous drainage of the frontal sinus. Even today, when antibiotic treatment is common, such rarities2 occur and plastic and reconstructive surgeons
1248 can be frequently required for the surgical management of these refractory skull infections.3 Spontaneous sinus drainage towards the skin of the forehead is a rare presentation of this disease. This sinocutaneous fistula is usually located in the frontal4,5 or orbital6,7 area because the anterior wall or floor of the frontal sinus, respectively, are frequently the pathways of least resistance for the infection. If even the posterior wall of the frontal sinus is broken, the fistula can complicate as epidural-cutaneous. This cutaneous sign can help to make accurate and prompt diagnosis and to provide correct treatment, avoiding serious potentially life threatening intracranial and systemic complications. In fact, swabs from discharging purulence are mandatory to isolate specific microorganisms and to administer correct antibiotics, independently from surgical approach. Aggressive craniotomy to remove all sequestra and cranial reconstructive surgery in combination with long-term culture-specific antibiotic therapy is the best treatment in advanced cases without intracranial complications, where the least invasive percutaneous or endonasal or combined endoscopic sinus surgery could be only partially successful. In our case report the presence of synthetic matter used for the first cranioplasty of the frontal bone has surely facilitated the development of this infectious disease, as well as making the success of antibiotic therapy alone impossible, leading to radical surgical removal of all prosthesis, infected collection and bone and secondary cranial reconstructive surgery through a mandatory open access. This rare condition should always be kept in mind among the possible differential diagnoses of the frontal soft tissue inflammatory and neoplastic diseases, in particular in patients with chronic sinusitis or previous cranial trauma, and radiological investigations such as CT and MRI could avoid the delayed diagnosis and possible emergency complications.8,9
References 1. Marshall AH, Jones NS. Osteomyelitis of the frontal bone secondary to frontal sinusitis. J Laryngol Otol 2000;114:944e6. 2. Kombogiorgas D, Solanki GA. The Pott puffy tumor revisited: neurosurgical implications of this unforgotten entity. Case report and review of the literature. J Neurosurg 2006;105:143e9. 3. West CA, Towns G, Bachelor AG, et al. Reconstruction of skull base and dura using rectus abdominis muscle combined with a vascularised fascial perforator flap. J Plast Reconstr Aesth Surg 2006;59:631e5. 4. Bellaney GJ, Ryan TJ. Pott’s puffy tumour. Br J Dermatol 1997; 136:145e7. 5. Goldfarb A, Hocwald E, Gross M, et al. Frontal sinus cutaneous fistula: a complication of Pott’s puffy tumor. Otolaryngol Head Neck Surg 2004;130:490e1. 6. Seyhan T, Ozerdem OR. Upper eyelid fistula caused by chronic frontal sinusitis. J Craniofac Surg 2005;16:171e4. 7. Hayek BR, Sitole S, Andreoli M, et al. Bilateral eyelid edema and orbital cellulitis associated with Pott’s puffy tumor. Ophthal Plast Reconstr Surg 2007;23:163e5. 8. Younis RT, Lazar RH, Anand VK. Intracranial complications of sinusitis: a 15-year review of 39 cases. Ear Nose Throat J 2002; 81:636e8. 640-2, 644. 9. Bambakidis NC, Cohen AR. Intracranial complications of frontal sinusitis in children: Pott’s puffy tumor revisited. Pediatr Neurosurg 2001;35:82e9.
Correspondence and communications E. Minutilli Department of Surgical Sciences, Catholic University of Sacred Heart, Rome, Italy E-mail address: [email protected] A. Pompucci C. Anile Department of Neurosurgery, Catholic University of Sacred Heart, Rome, Italy L. Corina G. Paludetti Department of ORL, Catholic University of Sacred Heart, Rome, Italy P. Magistrelli M. Castagneto Department of Surgical Sciences, Catholic University of Sacred Heart, Rome, Italy ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.01.026
Horrifying giant basal cell carcinoma of the face e A case report A 61-year-old man presented with a non healing ulcer of the face which had been present for the past 20 years. On examination, there was an ulcer on the left side of the face measuring 12 10 cm involving the pre-auricular, infra orbital and bucco mandibular units of the cheek and the orbit, with loss of vision. The supra orbital region, dorsum of the nose, ala, nasolabial fold, upper lip, angle of the mouth, maxilla, zygoma and frontal bones (Figure 1) were also involved. Biopsy revealed a moderately differentiated
Figure 1
Pre operative picture.
Correspondence and communications
Figure 2
Close-up view of BCC.
for all age groups, significantly 50e64s and 65e79s. However the largest average increase in incidence was noted in the 30e39s, though this fell short of statistical significance at the 5% level. Population-based studies have extrapolated current data to predict an almost exponential increase in BCC in the future, primarily in younger females.1 These observations suggest an alarming rise in the presentation of these cancers at younger ages and it is important to both raise awareness of this trend and to maintain a high index of suspicion in all age groups, even teenagers.
References 1. De Vries E, van de Poll-Franse LV, Louwman WJ, et al. Predictions of skin cancer incidence in the Netherlands up to 2015. Br J Dermatol 2005;152:481e8. 2. Christenson LJ, Borrowman TA, Vachon CM, et al. Incidence of basal cell and squamous cell carcinomas in a population younger than 40 years. JAMA 2005;294:681e90. 3. Bath-Hextall F, Leonardi-Bee J, Smith C, et al. Trends in incidence of skin basal cell carcinoma. Additional evidence from a UK primary care database study. Int J Cancer 2007;121:2105e8.
Helen E. Douglas Reena Agarwal David G.K. Lam Department of Plastic Surgery, Sorby 2, Northern General Hospital, Sheffield S5 7AU, United Kingdom E-mail address: [email protected] ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2007.12.065
Response to: ‘Malignant melanoma re-excision specimens: is there a need for histopathological analysis?’ McGoldrick et al., J PRAS 2008; 61:983e984 The paper from McGoldrick et al.1 reinforces the conventional view that it is unnecessary to examine re-excision
specimens from melanoma by extensive histological sampling where previous excision is complete. This will be welcome news to histopathologists, and also to laboratory managers struggling with their budgets. Those centres, and they do exist, where acres of unremarkable skin are routinely processed from re-excision specimens would do well to take note. As the authors correctly indicate, there may be other areas where resources could be more effectively diverted. However, the authors’ conclusions are radical. I wonder how many clinical units would be happy to have no histology at all? Current national recommendations, not always followed, suggest one block is sufficient. This does at least confirm a scar is present. I have personally encountered palmar, plantar and genital ‘re-excisions’ where histology showed this was not the case. Others may have had similar experiences. There are further considerations. Will all pathologists be happy to accept a surgical decision on the absence of macroscopically visible lesions? Who is going to independently assess the adequacy of the surgeon’s excision margin? Do all clinical teams have confidence in the quality of information relating to the completeness of previous excisions, especially where such information has been provided by another unit? The authors accept that there may be special circumstances where histology is needed. I suspect many other units will not ‘feel comfortable’ about consigning the remainder of their re-excisions to the waste disposer.
Reference 1. McGoldrick RB, Ng D, Sawyer A, et al. Malignant melanoma re-excision specimens: is there a need for histopathological analysis? J Plast Reconstr Aesthet Surg 2008;61:983e4.
Andrew Boon St James’s University Hospital, Leeds, UK E-mail address: [email protected] ª 2008 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. doi:10.1016/j.bjps.2007.10.058
Cutaneous fistula is a rare presentation of Pott’s puffy tumour Pott’s puffy tumour is a soft tissue swelling overlying osteomyelitis of the frontal bone rarely observed in postantibiotic clinical practice.1 This sub-periosteal abscess is usually secondary to frontal osteomyelitis caused by chronic paranasal sinusitis; it can be less frequently generated by skull traumas and diseases or fronto-nasal iatrogenic procedures. Streptococci, staphylococci or anaerobes are the most common offending microorganisms, with Haemophilus influenzae and fungi being the causative agents in exceptional cases. Possible complications are cutaneous fistulas,
Correspondence and communications
1247
neurological emergencies (meningitis, subdural, epidural or intracerebral abscesses, sagittal sinus thrombosis) and systemic sepsis. Diagnosis is often unfamiliar and late so that potentially life-threatening complications can develop. Multidisciplinary surgical intervention is commonly recommended and it can be more or less complicated in accordance with involved anatomical sites. This case report stresses the necessity of recognizing this rare soft tissue condition, avoiding misdiagnoses responsible for possible fatal consequences.
Case report A 55-year-old woman presented to our department with a 2-month history of a mid-forehead localized and illdefined non fluctuating swelling (Figure 1), accompanied with slight local pain and headache, which had been discharging purulence intermittently through a small cutaneous fistula for a few days. No systemic symptoms were present and laboratory tests were normal. In other departments this lesion had been mistaken for an inflamed epidermoid cyst and treated unsuccessfully with oral antibiotics and local lavage of the wound for a total period of 3e4 weeks. Eight years earlier she had undergone posttraumatic right frontal craniotomy and cranial osteoplastic reconstructive surgery by acrylic resins. During the first surgery the opening of the frontal sinus was required for the total exposure of the traumatic frontal lesion. She had no prior history of sinusitis and no sign of nasal discharge or ocular disturbances. The patient was otherwise healthy. Computerised tomography (CT) and magnetic resonance imaging (MRI) with gadolinium revealed frontal cellulitis and osteomyelitis extending to the right sinus and giving rise to a sinus-cutaneous fistula where there were evident radiological signs of past cranioplasty; subdural space involvement was excluded (Figure 2A). From a swab of the cutaneous discharge Staphylococcus aureus was isolated. The patient was subjected to aggressive surgery which consisted of the excision of the fistula tract, radical removal of the nonviable material, curettage of the
Figure 2 (A) Preoperative CT scan (bone window) shows soft tissue swelling overlying osteomyelitis of the frontal bone associated with right frontal sinusitis. The right frontal craniotomy was performed for a traumatic lesion. Poly-methylmetacrylate was used to cover the post-surgical defect in the midline of the forehead. (B) Postoperative CT scan (3D) shows the results of the cranial osteoplastic reconstructive surgery. After the removal of the right frontal bone and debridement of the infected tissue, the left frontal craniotomy was performed and bone flap split to achieve a complete covering of the exposed dura. The mucosa of the frontal sinus was pulled out and the posterior wall was removed.
osteomyelitic bone and reconstructive cranial osteoplasty by split autologous bone of the outer frontal table after obliterating sinus (Figure 2B). Postoperative culturespecific systemic antibiotics were administered for 8 weeks. Cosmetic and functional results have been satisfactory and no relapse or sequela have been observed after 2 years.
Discussion
Figure 1 Clinical appearance of frontal localized swelling discharging through a small cutaneous fistula surrounded by granulation tissue.
Pott’s puffy tumour is an uncommon but well recognized entity among otolaryngologists, neurosurgeons and plastic and reconstructive surgeons, rarely reported with references to its cutaneous presentation. The most frequent cause of this frontal cellulitis is represented by frontal osteomyelitis secondary to chronic sinusitis, especially in children. It occurs as a result of the infection spreading, i.e. direct extension from the sinus to the overlying bone or less probably through diploic venous drainage of the frontal sinus. Even today, when antibiotic treatment is common, such rarities2 occur and plastic and reconstructive surgeons
1248 can be frequently required for the surgical management of these refractory skull infections.3 Spontaneous sinus drainage towards the skin of the forehead is a rare presentation of this disease. This sinocutaneous fistula is usually located in the frontal4,5 or orbital6,7 area because the anterior wall or floor of the frontal sinus, respectively, are frequently the pathways of least resistance for the infection. If even the posterior wall of the frontal sinus is broken, the fistula can complicate as epidural-cutaneous. This cutaneous sign can help to make accurate and prompt diagnosis and to provide correct treatment, avoiding serious potentially life threatening intracranial and systemic complications. In fact, swabs from discharging purulence are mandatory to isolate specific microorganisms and to administer correct antibiotics, independently from surgical approach. Aggressive craniotomy to remove all sequestra and cranial reconstructive surgery in combination with long-term culture-specific antibiotic therapy is the best treatment in advanced cases without intracranial complications, where the least invasive percutaneous or endonasal or combined endoscopic sinus surgery could be only partially successful. In our case report the presence of synthetic matter used for the first cranioplasty of the frontal bone has surely facilitated the development of this infectious disease, as well as making the success of antibiotic therapy alone impossible, leading to radical surgical removal of all prosthesis, infected collection and bone and secondary cranial reconstructive surgery through a mandatory open access. This rare condition should always be kept in mind among the possible differential diagnoses of the frontal soft tissue inflammatory and neoplastic diseases, in particular in patients with chronic sinusitis or previous cranial trauma, and radiological investigations such as CT and MRI could avoid the delayed diagnosis and possible emergency complications.8,9
References 1. Marshall AH, Jones NS. Osteomyelitis of the frontal bone secondary to frontal sinusitis. J Laryngol Otol 2000;114:944e6. 2. Kombogiorgas D, Solanki GA. The Pott puffy tumor revisited: neurosurgical implications of this unforgotten entity. Case report and review of the literature. J Neurosurg 2006;105:143e9. 3. West CA, Towns G, Bachelor AG, et al. Reconstruction of skull base and dura using rectus abdominis muscle combined with a vascularised fascial perforator flap. J Plast Reconstr Aesth Surg 2006;59:631e5. 4. Bellaney GJ, Ryan TJ. Pott’s puffy tumour. Br J Dermatol 1997; 136:145e7. 5. Goldfarb A, Hocwald E, Gross M, et al. Frontal sinus cutaneous fistula: a complication of Pott’s puffy tumor. Otolaryngol Head Neck Surg 2004;130:490e1. 6. Seyhan T, Ozerdem OR. Upper eyelid fistula caused by chronic frontal sinusitis. J Craniofac Surg 2005;16:171e4. 7. Hayek BR, Sitole S, Andreoli M, et al. Bilateral eyelid edema and orbital cellulitis associated with Pott’s puffy tumor. Ophthal Plast Reconstr Surg 2007;23:163e5. 8. Younis RT, Lazar RH, Anand VK. Intracranial complications of sinusitis: a 15-year review of 39 cases. Ear Nose Throat J 2002; 81:636e8. 640-2, 644. 9. Bambakidis NC, Cohen AR. Intracranial complications of frontal sinusitis in children: Pott’s puffy tumor revisited. Pediatr Neurosurg 2001;35:82e9.
Correspondence and communications E. Minutilli Department of Surgical Sciences, Catholic University of Sacred Heart, Rome, Italy E-mail address: [email protected] A. Pompucci C. Anile Department of Neurosurgery, Catholic University of Sacred Heart, Rome, Italy L. Corina G. Paludetti Department of ORL, Catholic University of Sacred Heart, Rome, Italy P. Magistrelli M. Castagneto Department of Surgical Sciences, Catholic University of Sacred Heart, Rome, Italy ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.01.026
Horrifying giant basal cell carcinoma of the face e A case report A 61-year-old man presented with a non healing ulcer of the face which had been present for the past 20 years. On examination, there was an ulcer on the left side of the face measuring 12 10 cm involving the pre-auricular, infra orbital and bucco mandibular units of the cheek and the orbit, with loss of vision. The supra orbital region, dorsum of the nose, ala, nasolabial fold, upper lip, angle of the mouth, maxilla, zygoma and frontal bones (Figure 1) were also involved. Biopsy revealed a moderately differentiated
Figure 1
Pre operative picture.