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Pott's puffy tumour in adult
Otolaryngology Case Reports 11 (2019) 100106
Contents lists available at ScienceDirect
Otolaryngology Case Reports journal homepage: www.elsevier.com/locate/xocr
Pott's puffy tumour in adult a,∗
a
T a
Zuzana Horáková , Pavel Smilek , Břetislav Gál , Marta Pažourková a b
b
Clinic of Otorhinolaryngology Head and Neck Surgery, St.Anne´s University Hospital, Brno, Czech Republic Clinic of Radiology, St.Anne´s University Hospital, Brno, Czech Republic
A R T I C LE I N FO
A B S T R A C T
Keywords: Pott's tumour Forehead abscess Frontal sinusitis Endoscopic endonasal surgery
Pott's puffy tumour is a life threatening complication of infectious sinusitis which is the osteomyelitis of the frontal bone with associated subperiosteal abscess causing swelling and oedema over the forehead and scalp. Here we present a case a 70 year old male with a rare infectious complication of untreated sinusitis called Pott's puffy tumour which was diagnosed due to high clinical suspicion and confirmed with CT imaging. This case highlights the need to recognize and easily prevent this fatal complication of a seemingly benign infection like bacterial sinusitis. Unfortunately, if it does occur, clinicians can avoid missing the diagnosis by upholding a high clinical suspicion in the setting of known risk factors and must look for underlying causes both medical and psychosocial.
Introduction Pott's puffy tumour (PT) is an infrequent entity characterized by a subperiosteal abscess associated with frontal bone osteomyelitis. It has become rare in post antibiotic era. It is usually seen as a complication of frontal sinusitis. Although PT is more commonly described in children, it should be excluded in case of forehead swelling in adults. Once the diagnosis is suspected, appropriate imaging (CT, MRI) should evaluate the possible complications. The treatment combines medical and surgical approaches to drain the abscess to excise the infected bone and to prevent further complications. The endoscopic endonasal approach is a safe and effective alternative to the external one. This report describes the case of a 70-year-old man with Pott's puffy tumour resulting from frontal sinusitis [1]. Case report A 70 year old patient presented himself with a history of several year nasal obstruction, hyposmia and recurring sinusitis, without any treatment. 6 weeks ago he sustained an injury-he bummed his forehead against a car door. 3 days later a redish tender bulging emerged, slowly growing within days, becoming painful under palpation; 10 × 10cm soft, rounded with inflammed skin of forehead at admission [Fig. 1], with no nasal pathology under endoscopy. CT imaging revealed both anterior and posterior frontal sinus table bone destruction communicating intracranially and subperiostally MRI [Fig. 2] confirmed mucoor pyocoele of both frontal sinuses, with subperiostal absces of 7 × 6x3
∗
cm in size, expanding intraorbitally and intracranially. WBC and CRP were not elevated. The surgery was suggested via combined approach: endoscopic frontal sinotomy sec. Draf II, polyps and osteomyelitic bone was removed from the frotal ostium and thus pus discharged [Fig. 3]; no obvious anterior table bone osteomyelitis from endoscopic view, thus from an external approach, soft elastic bulging 11 × 10cm was incised, across the bulging, in a the supercilliar region, mucus and pus was drained, communication intracranially and into orbit through a bony defect was exposed [Fig. 4]. Cultivation guided antibiologic therapy with cefuroxim and metronidazole followed. Now he is symptom free one year after surgery. Discussion PT first described by Dr. Percival Pott In 1760 is defied by osteomyelitis of the frontal bone with associated well circumsribed subperiosteal abscess causing swelling and oedema over the forehead and scalp [2]. PT incidence having been much higher in the pre-antibiotic era is nowadays reported rarely in the pediatric population, adolescents respectively and very exceptionally in adults (only 18 cases of in adults > 15 years of age) [3]. The frontal sinuses develop from the ethmoid air cells and approach adult size between 12 and 13 years old when also the vascularity of the diploic veins peaks. This allows the sinus mucosa communication with the trabecular bone, which favours the development of osteomyelitis [4,5]. Most commonly in PT develops from an untreated frontal sinusitis
Corresponding author. n. SNP 23, Brno, 61300, Czech Republic E-mail address: [email protected] (Z. Horáková).
https://doi.org/10.1016/j.xocr.2019.01.007 Received 17 February 2018; Received in revised form 7 November 2018; Accepted 23 January 2019 Available online 31 January 2019 2468-5488/ © 2019 Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
Otolaryngology Case Reports 11 (2019) 100106
Z. Horáková, et al.
Fig. 1. Patient at time of admission.
Fig. 3. Endoscopic view: frontal sinus ostium with a pus discharge.
Fig. 2. MRI imaging prior to surgery.
Fig. 4. External surgical approach via anterior frontal sinus table.
which results in an osteomyelitis of the frontal sinus anterior table and subsequently an subperiosteal abscess. The anterior table is more susceptible to abscess formation (of a typical circumscribed appearance due to the adherence between periosteum and bone) [2,5]. A high risk for intracranial involvement and severe consequent complications (epidural abscess, subdural empyema, meningitis, cavernous or sagital sinus thrombosis) emerge in posterior sinus table involvement [2,4,6]. Latent, undiagnosed or partially treated frontal sinusitis spreads due to predisposing factors (frontal sinus trauma), hematogenously or via retrograde diploic veins thrombophlebitis which might be also a way of an intracranial involvement (with or without direct erosion of the frontal bone) [2]. Extremely rarely PT was reported secondary to insect
bites, malignancy, and acupuncture [2,6,7]. Sinus cultures obtained intraoperatively are often polymicrobial (including alpha and beta hemolytic Streptococci, Streptococcus pneumoniae, Staphylococcus, Haemophilus influenzae), intracranial complications are associated with anaerobes (including Fusobacterium, Bacteroides species) [2,6]. Although being a rare entity PT must be considered in any patient presenting with fluctuant, tender, erythematous swelling of the scalp. Due to previous inadequate treatment the typical picture might be reduced to a relatively indolent course (headache, rhinorrhea) and thus complicate the proper quick diagnostic setting. In intracranial or intraorbital involvement nausea, vomiting, lethargy, altered
2
Otolaryngology Case Reports 11 (2019) 100106
Z. Horáková, et al.
frontal sinus ostium via an endoscopic, external or combined approach.
consciousness cellulitis or orbital abscess might be observed [6,8]. Unfortunately, some patients might be still misdiagnosed as scalp abscess, undergo incision and drainage and are discharged from hospital. Besides, a characteristic clinical presentation, leukocytosis and elevated markers of inflammation, radiological imaging e.g. CT is essential for assessment of bony structures, MRI with gadolinium to precise extent of the disease intracranially. PT might become life threatening, hence a prompt diagnosis appropriate diagnosis and treatment is essentials for clinical outcome and reduction of severe intracranial complications (intracranial abscess, subdural and epidural empyema, cavernous sinus thrombosis and meningitis) are refered in 60–100%. The treatment combines medical and surgical access to secure drainage and infected bone resection, via an endoscopic, external or combined approach. Recent advances in endoscopic endonasal sugery provide safe and effective alternative (unless there is another such as an intracranial involvement) to an external approach. Interventions such as an external frontoethmoidectomy or craniotomy are less frequently needed. Infected bone and granulation tissue must be removed. Another option is to guarantee functional frontonasal duct. However, because the patient presented with extensive subcutaneous collection, the most appropriate approach for the case was external approach combined with endonasal endoscopic surgery [4,9]. After surgery a prolonged antibiotic therapy is necessary (6–8 week period is generally accepted) [9].
An author agreement/declaration All authors have seen and approved the final version of the manuscript being submitted. The article is the authors' original work, hasn't received prior publication and isn't under consideration for publication elsewhere. A conflict of interest There's no financial/personal interest or belief that could affect the objectivity. Acknowledgement This study was supported by the following research programme of the Grant Agency: GACR 16-12454S a AZV 16-29835. References [1] Grewal A, Dangaych NS, Esposito A. A tumor that is not a tumor but it sure can kill!. Am J Case Rep 2012;13:133–6. [2] Raja V, Low C, Sastry A, Moriarty B. Pott's puffy tumor following an insect bite. J Postgrad Med 2007;53(2):114–6. [3] Feder Jr. HM, Cates KL, Cementina AM. Pott puffy tumor: a serious occult infection. Pediatrics 1987 Apr;79(4):625–9. [4] Blackman SC, Schleiss MR. Forehead swelling caused by Pott's puffy tumor in a 9year-old boy with sinusitis. Pediatr Int 2005;47(6):704–7. [5] Forgie SE, Marrie TJ. Pott's Puffy tumor. Am J Med 2008;121(12):1041–2. [6] Wu CT, Huang JL, Hsia SH, Lee HY, Lin JJ. Pott's puffy tumor after acupuncture therapy. Eur J Pediatr 2009;168(9):1147–9. [7] Khan MA. Pott's puffy tumor: a rare complication of mastoiditis. Pediatr Neurosurg 2006;42(2):125–8. [8] Reynolds DJ, Kodsi SR, Rubin SE, Rodgers IR. Intracranial infection associated with preseptal and orbital cellulitis in the pediatric patient. J AAPOS 2003;7(6):413–7. [9] Jung J, Lee HC, Park I, Lee HM. Endoscopic endonasal treatment of a Pott's puffy tumor. Clin Exp Otorhinolaryngol 2012;5:112–5.
Conclusion A typical presentation of PT is headache, fever, and swollen forehead mass following injury in preexisting frontal sinusitis. It is rare now, in the postantibiotic era. However, early appropriate diagnosis based on CT and MRI imaging is essentials for clinical outcome and prevention of intracerebral complications, such as epidural, subdural, and brain abscesses. The treatment combines medical and surgical access to secure abscess drainage, infected bone resection and secure open
3
Contents lists available at ScienceDirect
Otolaryngology Case Reports journal homepage: www.elsevier.com/locate/xocr
Pott's puffy tumour in adult a,∗
a
T a
Zuzana Horáková , Pavel Smilek , Břetislav Gál , Marta Pažourková a b
b
Clinic of Otorhinolaryngology Head and Neck Surgery, St.Anne´s University Hospital, Brno, Czech Republic Clinic of Radiology, St.Anne´s University Hospital, Brno, Czech Republic
A R T I C LE I N FO
A B S T R A C T
Keywords: Pott's tumour Forehead abscess Frontal sinusitis Endoscopic endonasal surgery
Pott's puffy tumour is a life threatening complication of infectious sinusitis which is the osteomyelitis of the frontal bone with associated subperiosteal abscess causing swelling and oedema over the forehead and scalp. Here we present a case a 70 year old male with a rare infectious complication of untreated sinusitis called Pott's puffy tumour which was diagnosed due to high clinical suspicion and confirmed with CT imaging. This case highlights the need to recognize and easily prevent this fatal complication of a seemingly benign infection like bacterial sinusitis. Unfortunately, if it does occur, clinicians can avoid missing the diagnosis by upholding a high clinical suspicion in the setting of known risk factors and must look for underlying causes both medical and psychosocial.
Introduction Pott's puffy tumour (PT) is an infrequent entity characterized by a subperiosteal abscess associated with frontal bone osteomyelitis. It has become rare in post antibiotic era. It is usually seen as a complication of frontal sinusitis. Although PT is more commonly described in children, it should be excluded in case of forehead swelling in adults. Once the diagnosis is suspected, appropriate imaging (CT, MRI) should evaluate the possible complications. The treatment combines medical and surgical approaches to drain the abscess to excise the infected bone and to prevent further complications. The endoscopic endonasal approach is a safe and effective alternative to the external one. This report describes the case of a 70-year-old man with Pott's puffy tumour resulting from frontal sinusitis [1]. Case report A 70 year old patient presented himself with a history of several year nasal obstruction, hyposmia and recurring sinusitis, without any treatment. 6 weeks ago he sustained an injury-he bummed his forehead against a car door. 3 days later a redish tender bulging emerged, slowly growing within days, becoming painful under palpation; 10 × 10cm soft, rounded with inflammed skin of forehead at admission [Fig. 1], with no nasal pathology under endoscopy. CT imaging revealed both anterior and posterior frontal sinus table bone destruction communicating intracranially and subperiostally MRI [Fig. 2] confirmed mucoor pyocoele of both frontal sinuses, with subperiostal absces of 7 × 6x3
∗
cm in size, expanding intraorbitally and intracranially. WBC and CRP were not elevated. The surgery was suggested via combined approach: endoscopic frontal sinotomy sec. Draf II, polyps and osteomyelitic bone was removed from the frotal ostium and thus pus discharged [Fig. 3]; no obvious anterior table bone osteomyelitis from endoscopic view, thus from an external approach, soft elastic bulging 11 × 10cm was incised, across the bulging, in a the supercilliar region, mucus and pus was drained, communication intracranially and into orbit through a bony defect was exposed [Fig. 4]. Cultivation guided antibiologic therapy with cefuroxim and metronidazole followed. Now he is symptom free one year after surgery. Discussion PT first described by Dr. Percival Pott In 1760 is defied by osteomyelitis of the frontal bone with associated well circumsribed subperiosteal abscess causing swelling and oedema over the forehead and scalp [2]. PT incidence having been much higher in the pre-antibiotic era is nowadays reported rarely in the pediatric population, adolescents respectively and very exceptionally in adults (only 18 cases of in adults > 15 years of age) [3]. The frontal sinuses develop from the ethmoid air cells and approach adult size between 12 and 13 years old when also the vascularity of the diploic veins peaks. This allows the sinus mucosa communication with the trabecular bone, which favours the development of osteomyelitis [4,5]. Most commonly in PT develops from an untreated frontal sinusitis
Corresponding author. n. SNP 23, Brno, 61300, Czech Republic E-mail address: [email protected] (Z. Horáková).
https://doi.org/10.1016/j.xocr.2019.01.007 Received 17 February 2018; Received in revised form 7 November 2018; Accepted 23 January 2019 Available online 31 January 2019 2468-5488/ © 2019 Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
Otolaryngology Case Reports 11 (2019) 100106
Z. Horáková, et al.
Fig. 1. Patient at time of admission.
Fig. 3. Endoscopic view: frontal sinus ostium with a pus discharge.
Fig. 2. MRI imaging prior to surgery.
Fig. 4. External surgical approach via anterior frontal sinus table.
which results in an osteomyelitis of the frontal sinus anterior table and subsequently an subperiosteal abscess. The anterior table is more susceptible to abscess formation (of a typical circumscribed appearance due to the adherence between periosteum and bone) [2,5]. A high risk for intracranial involvement and severe consequent complications (epidural abscess, subdural empyema, meningitis, cavernous or sagital sinus thrombosis) emerge in posterior sinus table involvement [2,4,6]. Latent, undiagnosed or partially treated frontal sinusitis spreads due to predisposing factors (frontal sinus trauma), hematogenously or via retrograde diploic veins thrombophlebitis which might be also a way of an intracranial involvement (with or without direct erosion of the frontal bone) [2]. Extremely rarely PT was reported secondary to insect
bites, malignancy, and acupuncture [2,6,7]. Sinus cultures obtained intraoperatively are often polymicrobial (including alpha and beta hemolytic Streptococci, Streptococcus pneumoniae, Staphylococcus, Haemophilus influenzae), intracranial complications are associated with anaerobes (including Fusobacterium, Bacteroides species) [2,6]. Although being a rare entity PT must be considered in any patient presenting with fluctuant, tender, erythematous swelling of the scalp. Due to previous inadequate treatment the typical picture might be reduced to a relatively indolent course (headache, rhinorrhea) and thus complicate the proper quick diagnostic setting. In intracranial or intraorbital involvement nausea, vomiting, lethargy, altered
2
Otolaryngology Case Reports 11 (2019) 100106
Z. Horáková, et al.
frontal sinus ostium via an endoscopic, external or combined approach.
consciousness cellulitis or orbital abscess might be observed [6,8]. Unfortunately, some patients might be still misdiagnosed as scalp abscess, undergo incision and drainage and are discharged from hospital. Besides, a characteristic clinical presentation, leukocytosis and elevated markers of inflammation, radiological imaging e.g. CT is essential for assessment of bony structures, MRI with gadolinium to precise extent of the disease intracranially. PT might become life threatening, hence a prompt diagnosis appropriate diagnosis and treatment is essentials for clinical outcome and reduction of severe intracranial complications (intracranial abscess, subdural and epidural empyema, cavernous sinus thrombosis and meningitis) are refered in 60–100%. The treatment combines medical and surgical access to secure drainage and infected bone resection, via an endoscopic, external or combined approach. Recent advances in endoscopic endonasal sugery provide safe and effective alternative (unless there is another such as an intracranial involvement) to an external approach. Interventions such as an external frontoethmoidectomy or craniotomy are less frequently needed. Infected bone and granulation tissue must be removed. Another option is to guarantee functional frontonasal duct. However, because the patient presented with extensive subcutaneous collection, the most appropriate approach for the case was external approach combined with endonasal endoscopic surgery [4,9]. After surgery a prolonged antibiotic therapy is necessary (6–8 week period is generally accepted) [9].
An author agreement/declaration All authors have seen and approved the final version of the manuscript being submitted. The article is the authors' original work, hasn't received prior publication and isn't under consideration for publication elsewhere. A conflict of interest There's no financial/personal interest or belief that could affect the objectivity. Acknowledgement This study was supported by the following research programme of the Grant Agency: GACR 16-12454S a AZV 16-29835. References [1] Grewal A, Dangaych NS, Esposito A. A tumor that is not a tumor but it sure can kill!. Am J Case Rep 2012;13:133–6. [2] Raja V, Low C, Sastry A, Moriarty B. Pott's puffy tumor following an insect bite. J Postgrad Med 2007;53(2):114–6. [3] Feder Jr. HM, Cates KL, Cementina AM. Pott puffy tumor: a serious occult infection. Pediatrics 1987 Apr;79(4):625–9. [4] Blackman SC, Schleiss MR. Forehead swelling caused by Pott's puffy tumor in a 9year-old boy with sinusitis. Pediatr Int 2005;47(6):704–7. [5] Forgie SE, Marrie TJ. Pott's Puffy tumor. Am J Med 2008;121(12):1041–2. [6] Wu CT, Huang JL, Hsia SH, Lee HY, Lin JJ. Pott's puffy tumor after acupuncture therapy. Eur J Pediatr 2009;168(9):1147–9. [7] Khan MA. Pott's puffy tumor: a rare complication of mastoiditis. Pediatr Neurosurg 2006;42(2):125–8. [8] Reynolds DJ, Kodsi SR, Rubin SE, Rodgers IR. Intracranial infection associated with preseptal and orbital cellulitis in the pediatric patient. J AAPOS 2003;7(6):413–7. [9] Jung J, Lee HC, Park I, Lee HM. Endoscopic endonasal treatment of a Pott's puffy tumor. Clin Exp Otorhinolaryngol 2012;5:112–5.
Conclusion A typical presentation of PT is headache, fever, and swollen forehead mass following injury in preexisting frontal sinusitis. It is rare now, in the postantibiotic era. However, early appropriate diagnosis based on CT and MRI imaging is essentials for clinical outcome and prevention of intracerebral complications, such as epidural, subdural, and brain abscesses. The treatment combines medical and surgical access to secure abscess drainage, infected bone resection and secure open
3