Beyond the Sinus: Unmasking Pott's Puffy Tumor Through Imaging.

Pott's puffy tumor (PPT) is a rare yet severe complication of frontal sinusitis, characterized by localized forehead swelling resulting from osteomyelitis and subperiosteal abscess formation. This case report discusses a 15-year-old male patient who initially presented with upper respiratory tract symptoms. These progressed to seizures, leading to the identification of extensive sinusitis and significant intra-cranial complications. The case emphasizes the benefits of integrating multiple imaging modalities to improve diagnoses and patient care. Imaging findings facilitated early diagnosis and prompted urgent referrals to pediatric neurosurgery and otorhinolaryngology, allowing for timely surgical interventions which were vital in preventing further morbidity. This report underscores the importance of a multidisciplinary team approach in managing complex conditions like PPT, ensuring comprehensive care and optimal patient outcomes.

Clinical Outcome of Posterior Instrumented Stabilization and Transpedicular Decompression in Patients Presenting with Thoracic or Lumbar Spinal Tuberculosis in a Tertiary Care Center: A Descriptive Cross-sectional Study.

INTRODUCTION: Posterior instrumented stabilization is a commonly done surgery in spinal tuberculosis. This study aims to evaluate the clinical, radiological, and neurological outcomes of posterior instrumented stabilization and transpedicular decompression in thoracic and lumbar spinal tuberculosis. METHODS: A descriptive cross-sectional study was conducted for one and a half years with at least six months of follow-up in a tertiary care center. The study was approved by the Institutional Review Committee (Reference number: 119 (6-11-5) 2/075-076). Total sampling was done and the study included patients over 18 years of age with spinal tuberculosis of the thoracic or lumbar regions. These patients underwent posterior instrumented stabilization and transpedicular decompression at the tertiary care center. The age, site of involvement, Visual Analog Scale score for back pain, neurological status as per Frankel Neurology grading, and local kyphotic angle in X-ray were recorded. The median, interquartile range and percentage were calculated. The data was entered in Microsoft Excel 2016 and analysis was done using Epi Info software version 7.2. RESULTS: Thoracic level was most commonly involved in 14 (46.68%) cases. The median back pain as assessed by the Visual Analogue Scale score improved from 8 to 2 at the 6-month follow-up. There was improvement in the neurological grading of all cases and there was no loss of correction in the local kyphotic angle till the final follow-up. The median age of cases was 48 years (interquartile range: 28-62.50). CONCLUSIONS: Posterior instrumented stabilization and transpedicular decompression in adult patients with thoracic or lumbar spinal tuberculosis achieves improvements in clinical, radiological, and neurological outcomes.

Non-traumatic spinal cord injury - etiological profile and associated factors: single rheumatological center experience.

Introduction: Non-traumatic spinal cord injury (NTSCI) represents a medical-surgical emergency. In Burkina Faso, limited data exist on the etiological profiles of this syndrome in rheumatology. This study aimed to describe the etiological profile of NTSCI in the Rheumatology Department of the University Hospital Center of Bogodogo (CHU-B). Material and methods: This was a cross-sectional, retrospective study with descriptive and analytical aims, conducted from March 1, 2017, to December 31, 2023, in the Rheumatology Department of CHU-B. Patients diagnosed with non-traumatic spinal cord compression syndrome during hospitalization were included. Results: The frequency in the Rheumatology Department of NTSCI was 2.94%, accounting for 104 patients. There were 68 men (65.38%), with a sex ratio of 1.88. The average age of the population was 57.91 years. All patients experienced back pain, with a lumbar location in 77 patients (74.04%). The average duration of the motor deficit was 2.97 months. A total of 3,532 patients were admitted to the conventional hospitalization unit of the Rheumatology Department at the CHU-B from March 1, 2017, to December 31, 2023. Among these, 104 patients had NTSCI, yielding a frequency of 2.94%. Spinal MRI was performed in 58 patients (55.77%), and the compression was extradural in 76.92% of cases (n = 80). The etiologies identified were Pott's disease in 32 patients (30.77%), followed by spinal metastases in 22 patients (21.15%). Twenty-nine patients (27.89%) experienced complications related to prolonged bed rest. No factor was significantly associated with the recovery of the motor deficit. Conclusions: Non-traumatic spinal cord injury is relatively rare in rheumatological practice in Ouagadougou. The etiology is predominantly Pott's disease, which confirms the geographical distribution of NTSCI causes.

Management of a Pott puffy tumor: Case report and literature review.

INTRODUCTION AND IMPORTANCE: Frontal bone osteomyelitis associated with a subperiosteal abscess is known as Pott's puffy tumor. Pott puffy tumor (PPT) is a rare entity that mainly affects children and adolescents. It is less common in adults, accounting for 30 % of cases, and predominates in men. The therapeutic management of Pott's puffy tumor is an emergency and is based on a combination of antibiotic therapy and surgical treatment to prevent the emergence of intracranial complications and reduce morbidity and mortality. CASE PRESENTATION: We report the case of a 29-year-old female patient, who consulted our ENT (ear, nose, and throat) department for a post-traumatic periorbital swelling. CT scan confirmed osteomyelitis of the frontal bone and subperiosteal abscess. The patient underwent a combined surgical drainage with antibiotics. The aim is to describe an effective management of this clinical case. CLINICAL DISCUSSION: This condition presents as a subperiosteal/subgaleal abscess creating a frontal swelling, with osteomyelitis of the frontal bone most often secondary to frontal sinusitis. The most feared complications are intracranial, which can be life-threatening. Imaging is the key to positive diagnosis, as the evolution and prognosis of TPP depend on rapid management. A CT scan of the head is the examination of choice to confirm the diagnosis. Antibiotic therapy should be started as soon as possible, it is usually administered by intravenous injection. Surgical management may be limited to percutaneous drainage by needle or transnasal endoscopy or trephination, sometimes including trimming of the subperiosteal/subgaleal abscess. In the case of intracranial complications, a craniotomy may be necessary. CONCLUSION: The Pott's puffy tumor is little-known complication, usually secondary to untreated or poorly treated sinusitis. As a result of this poor understanding, the condition can lead to complications, especially intracranial ones, which increase morbidity and mortality.

Disparities in the Clinical Profile of Spinal Tuberculosis in Africa: A Scoping Review of Management and Outcome.

BACKGROUND: Spinal tuberculosis (STB) is a significant contributor to nontraumatic myelopathy. There is a rising burden in Africa, in parallel with the high prevalence of human immunodeficiency virus. We conducted a scoping review to highlight the disparities in the management and outcomes of STB in Africa. METHODS: This study was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping review guidelines. AJOL, Embase, MEDLINE, Google Scholar, and Cochrane CENTRAL databases were searched to identify all relevant peer-reviewed articles published on the management of STB in African centers, excluding abstract-only articles, literature reviews, and meta-analyses. RESULTS: Sixty studies were eligible for inclusion, comprising data from 3416 patients aged 8 months to 89 years (median, 32 years). Thoracic and lumbar segments were the most commonly affected vertebral regions (thoracic = 42.7%; lumbar = 35.9%). The most common clinical features were back pain and neurological deficits. Lack of essential laboratory and imaging diagnostic infrastructure was a common problem. Patients received antitubercular therapy (ATT) for varying durations, and only 18.3% underwent surgery. A favorable outcome was achieved in 51.6% of patients, 20.3% developed a permanent disability, and the mortality rate was 2.1%. Treatment outcome was adversely affected by a high rate of late presentation and treatment default. CONCLUSIONS: ATT remains the mainstay of treatment; however, the duration of treatment varied widely among studies. Further research is required to explore the feasibility and efficacy of short-course ATT in treating STB in the African population.

Pott's puffy tumor with intracranial extension in a child with incontinentia pigmenti: case based review of the eponymous disease.

BACKGROUND: Pott's puffy tumor (PPT) is an uncommon infection involving the frontal bone, first described by Sir Percival Pott more than 250 years ago. It can present with intracranial extension and serious neurological morbidity. Incontinentia pigmenti (IP) is a rare inherited genodermatosis that is lethal prenatally in males and manifests clinically in females. IP is associated with recurrent infections and immune dysfunction/suppression. METHODS: We report a case of Pott's puffy tumor presenting in a child with IP. We also performed a literature review of reported cases of PPT associated with immune dysfunction. We discuss the clinical presentation, diagnosis, and management of these lesions. RESULTS: We identified 12 cases of PPT associated with immune dysfunction/suppression. Diabetes was the most commonly identified cause followed by iatrogenic immunosuppression. Surgery is the standard treatment for managing PPT and the management of PPT with and without intracranial involvement, particularly in the context of underlying immune dysfunction/suppression, is discussed. CONCLUSION: PPT remains a rare but not infrequent diagnosis, often requiring neurosurgical intervention. Immune dysfunction/suppression is an additional risk factor that may predispose to PPT. Early and aggressive management should be instituted for optimal outcome.

Frontal Sinus Mucopyocele Presenting as a Painful Subcutaneous Forehead Mass in a Patient with Chronic Sinusitis.

Mucoceles of the paranasal sinuses are benign, expansile lesions that develop secondary to sinus ostia obstruction. Presenting signs and symptoms vary widely but frequently include frontal headache and swelling, as well as visual changes and globe displacement depending on orbital involvement in the case of frontal sinus mucoceles. Given the potential for orbital or intracranial involvement, urgent imaging with computed tomography (CT) is important for patients with symptoms concerning for a frontal sinus mucocele. Definitive treatment is surgical. In this article, we report a case of a 50-year-old male who presented to a primary care clinic with a painful forehead mass, found to have a frontal sinus mucocele with erosion through the frontal bone that was eventually treated surgically. We also summarize presenting signs and symptoms of frontal mucoceles reported in the literature as these are important for clinicians to be familiar with, considering the potential emergent complications.

Tongue Tuberculosis as a Complication of Pott's Disease in a Patient on Systemic Steroid Therapy without Pulmonary Tuberculosis.

A 78-year-old man with a previous diagnosis of rheumatoid arthritis on prolonged treatment with corticosteroids presented with intense and progressive pain at the cervical level that prevented him from resting his head and walking, in addition to an ulcerative lesion covering 80% of the lingual area that was previously treated as oral candidiasis without improvement. On arrival, with no clinical or serological data of rheumatoid arthritis, immunosuppressive treatment was suspended, and a biopsy of the oral cavity was requested, confirming the diagnosis of lingual tuberculosis, an extremely rare disease, occurring in less than 1% of extrapulmonary cases. MRI of the cervical spine showed a crush fracture of the C6 and C7 bodies associated with spondylitis of probably infectious etiology that required surgical treatment, and histopathological studies confirmed Pott's disease. The patient displayed no evidence of pulmonary tuberculosis from arrival until the end of the follow-up.

El tumor inflamatorio de Pott: una complicación infrecuente de la sinusitis. Reporte de caso / Pott's puffy tumor: A rare complication of sinusitis. A case report

Una complicación infrecuente de la sinusitis frontal es el tumor inflamatorio de Pott. Se manifiesta como una tumefacción en la frente por la presencia de un absceso subperióstico secundario a una osteomielitis del hueso frontal. El diagnóstico oportuno permite un tratamiento intensivo médico y quirúrgico precoz, esencial para evitar complicaciones intracraneales graves. Se presenta el caso de un varón de 12 años con un tumor inflamatorio de Pott como complicación de una pansinusitis. Representó un desafío diagnóstico; sin embargo, la instauración del tratamiento oportuno permitió una evolución clínica favorable.

A rare complication of frontal sinusitis includes Pott's puffy tumor. It manifests as a swelling of the forehead due to the presence of a subperiosteal abscess secondary to osteomyelitis of the frontal bone. A timely diagnosis allows for an early, intensive medical and surgical treatment, which is critical to prevent serious intracranial complications. Here we describe the case of a 12-year-old boy with Pott's puffy tumor as a complication of pansinusitis. This case was a diagnostic challenge; however, a timely treatment allowed for a favorable clinical course.

Complicated Odontogenic Sinusitis: Extrasinus Infectious Spread.

Odontogenic sinusitis (ODS) is a common cause of orbital, intracranial, and osseous infectious extrasinus complications. Dental infections can spread to the orbital or intracranial spaces though the sinuses via thrombophlebitis or direct extension, or from the dentition or oral cavity via vascular channels in the maxillary alveolar bone. ODS typically presents with unilateral involvement both clinically and radiographically. Any suspicion for extrasinus spread based on history and physical examination should be followed by appropriate imaging, formal dental evaluation, and, when appropriate, ophthalmology and neurosurgery consultations. This multidisciplinary approach ensures appropriate management of both the acute orbital and intracranial complications.

Clinical Management and Neurosurgical Approach of Pott's Puffy Tumor: A Case Report.

Pott's puffy tumors are assumed to be infrequent concomitant intra- and extracranial abscesses, mainly secondary to complicated frontal sinusitis during infancy. Due to the close proximity to the superior sagittal sinus, there is a risk of developing venous infections, thrombosis, and morbidity. In this case report, we present a case of an 11-year-old girl who presented with headache and face edema. After recognizing the Pott's puffy tumor pattern on the CT scan and brain MRI, the neurosurgical approach involved pus evacuation and frontal sinus blockage, and the patient received antibiotic therapy and was evaluated for total recovery. To our knowledge, the prompt diagnosis and treatment of such conditions are paramount to avoid complications, and differential diagnosis should be encouraged in medical practice.

Rare case of Pott's puffy tumor due to nasal foreign body.

Background: Pott's Puffy tumor (PPT) is a complicated frontal sinusitis that is also described as frontal bone osteomyelitis and a localized sub periosteal abscess. Early diagnosis and immediate active treatment are necessary to prevent severe neurologic sequelae. Case Presentation: Here, we report on a case of Pott's puffy tumor in a previously healthy 13-year-old girl with a worsening headache and swelling of the frontal bone accompanied by vomiting and fever. Magnetic resonance imaging revealed osteomyelitis of the frontal bone. A foreign body was discovered and removed via endoscopy which was then followed by 6 weeks of parenteral and enteral antibiotic therapy, resulting in resolution of all symptoms. Conclusion: A complete history in terms of trauma and insect bite or foreign body in the nose is paramount for a correct diagnosis, and performing a full examination of ear, nose and throat (ENT) to rule out a foreign body is advised.

Síndrome medular completo secundario a mielitis infecciosa causada por Mycobacterium tuberculosis. Informe de caso / Central spinal cord syndrome secondary to infectious myelitis caused by Mycobacterium Tuberculosis

Introducción: La tuberculosis, un problema de salud pública a nivel mundial que afecta a la población. Causada por Mycobacterium tuberculosis, se transmite a través de gotas de saliva y la presentación extrapulmonar afecta 5­45% de la población infectada. La tuberculosis de columna vertebral es una enfermedad crónica y progresiva, secundaria a la diseminación de un foco primario, que puede pasar desapercibido. Descripción del caso: Paciente masculino con fiebre de 4 días de evolución, nocturna, con diaforesis, debilidad de fuerza de miembros superiores e inferiores bilateral; miembros inferiores con (0) fuerza y miembros superiores (1), ausencia de reflejos osteotendinosos en ambas extremidades, nivel sensitivo C4, con ausencia de control de esfínteres. El diagnóstico se estableció mediante toracocentesis diagnóstica, realizando GeneXpert y cultivo de líquido pleural, positivo para tuberculosis y negativo para micobacteria resistente; resonancia magnética con gadolinio identifica área hiperintensa cervical medular de C2 hasta C4, produciendo aumento en el diámetro de la médula espinal. Se inició tratamiento tetraconjugado: isoniazida, rifampicina, pirazinamida y etambutol. Cuatro semanas posteriores al comienzo de tratamiento paciente presenta (2) fuerza en miembros inferiores y (3) en miembros superiores, continuando con terapia física. Conclusión: la tuberculosis se presenta de maneras muy diversas y se debe tener presente en pacientes jóvenes sin antecedentes personales patológicos que presenten cuadros de fiebre como uno de los primeros síntomas. Pruebas diagnósticas serológicas, GeneXpert y de imagen como la resonancia magnética ayudan en establecer un diagnóstico. La tuberculosis debe considerarse siempre en un proceso infeccioso que se desconoce etiología...(AU)

The Relationship Between Destruction Sites and Clinical Findings in Diffuse Paranasal Sinus Mucoceles.

Objective: This study aimed to investigate that complicated mucoceles of paranasal sinuses and their clinical presentation, complications of relations with size, destructions areas, extension limits in affected patients. Materials and methods: A retrospective review was performed on patients who were diagnosed and treated as paranasal sinus mucoceles at ENT department from 2002 to 2013 years. Patients' demographic data, mucoceles location, symptoms, surgical approach and complications were evaluated. Results: The study group included 9 male and 10 female patients with a mean age of 45,0 years (range, 12-76 years). This case series include fronto-ethmoidal complex (52,6%), followed by frontal (26,3%), maxillary (15,7%) and sphenoid sinus mucoceles (5,2%). Endoscopic sinus surgery (ESS) was performed on 11 patients (57.8%); endoscopic procedures included marsupialization through an infundibulotomy, associated with an anterior ethmoidectomy and maxillary sinus antrostomy. Four patients (21%) underwent an external surgical procedure. 8 patients (42%) were treated by a combination of both endoscopic and external approaches such as trephination of the anterior wall of the frontal sinus, osteoplastic flap approach, Caldwell-Luc operation, anterior craniotomy and Lynch procedure. Complications occurred only in 2 cases (10.5%). Conclusion: The majority of patients with extensive paranasal sinus mucoceles exhibited ophthalmologic and intracranial symptoms. A satisfactory outcome can be achieved after surgical treatment of both endoscopic and external approaches.

Navigating Perioperative Challenges in Pott's Spine: A Comprehensive Review.

Pott's spine, or tuberculous spondylitis, remains a significant public health concern in regions where tuberculosis is endemic. The management of Pott's spine poses unique perioperative challenges due to the complexity of the disease process, including vertebral destruction, spinal instability, and neurological compromise. This comprehensive review explores the intricacies of navigating perioperative challenges in Pott's spine surgery. Beginning with an overview of Pott's spine, including its etiology, clinical presentation, and classification, the review delves into the significance of perioperative challenges in this condition. Emphasis is placed on the need for multidisciplinary collaboration, meticulous preoperative assessment, and tailored surgical planning to optimize outcomes while minimizing the risk of complications. Critical considerations in the preoperative, intraoperative, and postoperative phases of care are discussed in detail, including patient assessment, imaging modalities, surgical techniques, anesthesia considerations, and postoperative rehabilitation. Special considerations such as pediatric Pott's spine and multidrug-resistant tuberculosis are also addressed. The review concludes by summarizing key points, highlighting implications for clinical practice, and providing recommendations for future research. By synthesizing current evidence and clinical expertise, this review offers valuable insights into the optimal management of perioperative challenges in Pott's spine, ultimately aiming to improve patient outcomes and reduce the burden of this debilitating condition.

Multi-level tuberculosis of the spine identified by 18 F-FDG-PET/CT and concomitant urogenital tuberculosis: a case report from the spinal TB X cohort.

BACKGROUND: Tuberculosis (TB) is caused by Mycobacterium tuberculosis (Mtb) and typically infects the lungs. However, extrapulmonary forms of TB can be found in approximately 20% of cases. It is suggested, that up to 10% of extrapulmonary TB affects the musculoskeletal system, in which spinal elements (spinal tuberculosis, STB) are involved in approximately 50% of the cases. STB is a debilitating disease with nonspecific symptoms and diagnosis is often delayed for months to years. In our Spinal TB X Cohort, we aim to describe the clinical phenotype of STB using whole-body 18 F-fluorodeoxyglucose positron emission tomography computed tomography (PET/CT) and to identify a specific gene expression profile for the different stages of dissemination on PET/CT. Here we report on the first patient recruited into our cohort who underwent PET/CT before treatment initiation, at 6-months and at 12-months - time of TB treatment completion. CASE PRESENTATION: A 27-year-old immunocompetent male presented with severe thoracolumbar back pain for 9 months with severe antalgic gait and night sweats. Magnetic resonance imaging (MRI) of the whole spine revealed multilevel spinal disease (T5/6, T11/12, L3/4) in keeping with STB. After informed consent and recruitment into the Spinal TB X Cohort, the patient underwent PET/CT as per protocol, which revealed isolated multilevel STB (T4-7, T11/12, L3/4) with no concomitant lung or urogenital lesion. However, sputum and urine were Xpert MTB/RIF Ultra positive and Mtb was cultured from the urine sample. CT-guided biopsy of the T11/12 lesion confirmed drug-sensitive Mtb on Xpert MTB/RIF Ultra and the patient was started on TB treatment according to local guidelines for 12 months. The 6-month follow-up PET/CT revealed new and existing spinal lesions with increased FDG-uptake despite significant improvement of clinical features and laboratory markers. After 9 months of treatment, the patient developed an acute urethral stricture, most likely due to urogenital TB, and a suprapubic catheter was inserted. The 12-month PET/CT showed significantly decreased PET/CT values of all lesions, however, significant persistent spinal inflammation was present at the end of TB treatment. Clinically, the patient was considered cured by the TB control program and currently awaits urethroplasty. CONCLUSIONS: In our case, PET/CT emerged as a valuable imaging modality for the initial assessment, surpassing MRI by revealing more comprehensive extensive disease. Subsequent PET/CT scans at 6-month uncovered new lesions and increased inflammation in existing ones, while by the end of TB treatment, all lesions exhibited improvement. However, the interpretation of FDG avidity remains ambiguous, whether it correlates with active infection and viable Mtb. or fibro- and osteoblast activity indicative of the healing process. Additionally, the absence of extraspinal TB lesions on PET/CT despite positive microbiology from sputum and urine maybe explained by paucibacillary, subclinical infection of extraspinal organs. The Spinal TB X Cohort endeavours to shed light on whole-body imaging patterns at diagnosis, their evolution midway through TB treatment, and upon treatment completion. Ultimately, this study aims to advance our understanding of the biology of this complex disease.

A Case of Pott's Puffy Tumor in a Patient With Eosinophilic Chronic Rhinosinusitis.

Eosinophilic chronic rhinosinusitis (ECRS) is a refractory type 2 inflammation-based airway allergic disease that is prone to complications such as bronchial asthma. Pott's puffy tumor (PPT) is a rare clinical entity characterized by osteomyelitis of the frontal bone accompanied by a subperiosteal abscess. A 56-year-old female with a history of cranial surgery and bronchial asthma presented to an otolaryngology clinic with nasal obstruction and loss of smell, later developing swelling and redness on her forehead. She was diagnosed and treated for ECRS and was thought to have developed PPT during her course. Nasal endoscopy reveals bilateral polyp formation originating from the middle meatus. Paranasal computed tomography (CT) indicates substantial swelling extending from the opening of the frontal sinus to the adjacent subcutaneous tissue, accompanied by a defect in the frontal bone and osteolysis at the base of the frontal skull. Her management included conservative antibiotic therapy adjusted due to a drug eruption and, subsequently, endoscopic sinus surgery (ESS). The case was complicated by the patient's medical history and the absence of detailed surgical records, which limited the use of enhanced imaging techniques. This underscores the complexity of diagnosing and managing PPT in adults, particularly those with prior surgeries, emphasizing the need for a tailored diagnostic and therapeutic approach that integrates detailed patient history with current clinical indicators to effectively guide treatment. This case contributes to the limited literature on adult PPT and underscores the critical need for careful patient monitoring and detailed surgical history.

Comparing gene expression profiles of adults with isolated spinal tuberculosis to disseminated spinal tuberculosis identified by 18FDG-PET/CT at time of diagnosis, 6- and 12-months follow-up: classifying clinical stages of spinal tuberculosis and monitoring treatment response (Spinal TB X cohort study).

BACKGROUND: Tuberculosis (TB) is one of the top ten causes of death worldwide, with approximately 10 million cases annually. Focus has been on pulmonary TB, while extrapulmonary TB (EPTB) has received little attention. Diagnosis of EPTB remains challenging due to the invasive procedures required for sample collection. Spinal TB (STB) accounts for 10% of EPTB and often leads to lifelong debilitating disease due to devastating spinal deformation and compression of neural structures. Little is known about the extent of disease, although both isolated STB and a disseminated form of STB have been described. In our Spinal TB X cohort study, we aim to describe the clinical phenotype of STB using whole-body 18FDG-PET/CT, identify a specific gene expression profile for different stages of dissemination and compare findings to previously described gene expression signatures for latent and active pulmonary TB. METHODS: A single-centre, prospective cohort study will be established to describe the distributional pattern of STB detected by whole-body 18FDG-PET/CT and gene expression profile of patients with suspected STB on magnetic resonance imaging (MRI) at point of diagnosis, six months, and 12 months. Blood biobanking will be performed at these time points. Specimens for microbiology will be obtained from sputum/urine, from easily accessible sites of disease (e.g., lymph nodes, abscess) identified in the first 18FDG-PET/CT, from CT-guided biopsy and/or surgery. Clinical parameters and functional scores will be collected at every physical visit. Data will be entered into RedCap® database; data cleaning, validation and analysis will be performed by the study team. The University of Cape Town Ethics Committee approved the protocol (243/2022). DISCUSSION: The Spinal TB X cohort study is the first prospective cohort study using whole-body 18FDG-PET/CT scans in patients with microbiologically confirmed spinal tuberculosis. Dual imaging techniques of the spine using 18FDG-PET/CT and magnetic resonance imaging as well as tissue diagnosis (microbiology and histopathology) will allow us to develop a virtual biopsy model. If successful, a distinct gene-expression profile will aid in blood-based diagnosis (point of care testing) as well as treatment monitoring and would lead to earlier diagnosis of this devastating disease. TRIAL REGISTRATION: The study has been registered on ClinicalTrials.gov (NCT05610098).

Overview.

The chapter begins with also an outline of the characteristics of four surgeons who changed the direction of thinking and hence of practice. This is followed by a review of the changing ideas which governed surgical practice. Chapter "Two surgical instruments" by Jeremy C. Ganz has examined the uses of drills and lenticulars. In this chapter there is an appraisal of the other instruments used during cranial surgery and how their use related to changing ideas. Finally, there is a concluding section which ties all these elements together.

Pott's puffy tumor: An unusual complication of rhino-orbito-cerebral mucormycosis.

Objective: To describe clinicoradiological features and surgical outcomes in a series of nine patients with rhino-orbito-cerebral mucormycosis (ROCM) who presented with Pott's puffy tumor (ROCM-PPT). Methods: The records of nine patients with ROCM-PPT seen between March 2020 and December 2021 were analysed. Clinical features, radiology, histopathology, operative findings, management and outcome were noted. Frontal sinus pneumatisation and outflow tract configuration was compared between patients and controls with ROCM and no PPT. Results: ROCM-PPT was diagnosed in 9 of 284 (3.2 %) patients with ROCM seen during the study period. There were six (66.7 %) males and the median age was 54 (IQR 46-60) years. Eight (88.9 %) patients had diabetes mellitus and seven (77.8 %) had been COVID-19 positive. Radiological features of osteomyelitis, subperiosteal abscess formation and dural enhancement were seen in all patients. No significant differences in pneumatisation or frontal sinus outflow tract configuration were noted between patients and controls. All patients underwent a craniectomy with frontal bone debridement and frontal sinus exteriorisation. All patients were treated with anti-fungal agents for several months. All patients had symptomatic improvement at a median follow-up of 21 (IQR 18-23) months. Repeat CT/MRI scans showed disease regression/resolution in six out of eight (75 %) patients with follow-up imaging, and stable disease in two others. Conclusions: ROCM-PPT is a rare, delayed complication of mucormycosis that was seen in larger numbers during the recent COVID-19 pandemic. Aggressive debridement of osteomyelitic bone and antifungal therapy results in a good outcome.