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.

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.

Pott's Puffy Tumor: A Case Report on Diagnosis Through Imaging.

Pott's puffy tumor (PPT) is a rare but life-threatening complication of chronic sinusitis, although it can be secondary to other entities such as trauma or insect bites. It is characterized by circumscribed frontal swelling associated with a subperiosteal abscess. Imaging plays a crucial role in diagnosis and early identification of complications, some of which can be life-threatening, including intracerebral and intra-orbital complications. We present a case of a 14-year-old male with non-specific frontal pain and swelling, where the diagnosis of PTT was confirmed through imaging studies. Upon admission, the patient exhibited orbital and intracerebral complications, as shown in MRI and CT scans. Treatment involved a combination of antibiotics and sinus surgery, with close monitoring for orbital and intracranial complications.

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.

Pott's puffy tumor of the upper eyelid misdiagnosed as simple abscess: a case report and literature review.

A 76-year-old woman, initially thought to have a simple abscess on her right upper eyelid, presented to our department of plastic and reconstructive surgery. Enhanced three-dimensional facial computed tomography (CT) revealed an abscess on the right upper lid, with a pyomucocele present in the right frontal sinus, accompanied by bone erosion in the superior wall of the right orbit. Based on the results of the CT scan, we diagnosed an atypical Pott's puffy tumor (PPT) with an abscess on the upper lid originating from the frontal sinusitis. First, surgical incision and drainage were performed in our department, and a percutaneous vacuum drain was placed. To provide a more definitive treatment, endoscopic sinus surgery (ESS) was subsequently performed by otorhinolaryngologists. The patient was discharged without any complications 5 days after ESS. At a 1-year follow-up, no recurrence or notable neurological symptoms were observed. In the case we observed, the patient presented with an upper eyelid abscess and cellulitis, indicating possible orbital involvement. For such patients, a CT scan is necessary. Given the possibility of PPT, it is critical to perform a comprehensive differential diagnosis rather than defaulting to a straightforward approach involving abscess treatment.

[Characteristics and therapeutic strategies of Pott's puffy tumor].

Objective:To explore the characteristics and therapeutic strategies of Pott's puffy tumor（PPT）. Methods:The clinical data of two patients with PPT were retrospectively analyzed and combined with the literature, focusing on the comprehensive analysis of perioperative diagnosis and treatment strategies. Both patients underwent muti-disciplinary treatment, including timely administration of sufficient antibiotics capable of penetrating the blood-brain barrier. Early removal of PPT lesions was performed using a combined internal and external approach under nasal endoscopic guidance. Results:After standardized perioperative management, the symptoms of the two patients were completely relieved, with no recurrence after one=year follow=up. Postoperative complications such as frontal pain, numbness, local depression, or scar hyperplasiawere not present. Conclusion:PPT, being relatively rare and severe, requires careful attention. Key strategies for standardized perioperative management include multi-disciplinary consultation, timely and adequate antibiotic administration, and surgical intervention using a combined intranasal and extranasal endoscopic approach for lesion removal.

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

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.

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.

Characteristics and therapeutic strategies of Pott's puffy tumor / 临床耳鼻咽喉头颈外科杂志

Objective:To explore the characteristics and therapeutic strategies of Pott's puffy tumor（PPT）. Methods:The clinical data of two patients with PPT were retrospectively analyzed and combined with the literature, focusing on the comprehensive analysis of perioperative diagnosis and treatment strategies. Both patients underwent muti-disciplinary treatment, including timely administration of sufficient antibiotics capable of penetrating the blood-brain barrier. Early removal of PPT lesions was performed using a combined internal and external approach under nasal endoscopic guidance. Results:After standardized perioperative management, the symptoms of the two patients were completely relieved, with no recurrence after one=year follow=up. Postoperative complications such as frontal pain, numbness, local depression, or scar hyperplasiawere not present. Conclusion:PPT, being relatively rare and severe, requires careful attention. Key strategies for standardized perioperative management include multi-disciplinary consultation, timely and adequate antibiotic administration, and surgical intervention using a combined intranasal and extranasal endoscopic approach for lesion removal.

Acute Lower Lip Swelling: A Mere Anaphylactic Reaction or a Rare Abscess Location?

An abscess is a collection of pus secondary to an immune response to a pathogen. It can occur anywhere in the body, with the skin as the most common organ involved. A lip abscess is a rare condition. Generally, it may be due to an infective agent such as a virus or bacteria entering through a skin wound, or through hematogenous spread when there is a severe underlying condition such as a general condition disorder or immunodeficiency. It requires hypervigilance during the examination and throughout the treatment course with intravenous antibiotic therapy and urgent surgical drainage, as it may cause significant complications regarding localization, lymphovascular drainage, and ultimate spread. Persistent abscess, necrotic tissue, or cavitated lesions are worrisome and it is important to rule out immunosuppression or a methicillin-resistant staphylococcus. In this case, a 22-year-old male patient with a unilateral lip abscess, misdiagnosed as an allergic food reaction, responded well to external drainage and antibiotic therapy.

Tumor inflamatorio de Pott en escolar de 7 años: a propósito de un caso

El tumor inflamatorio de Pott (PPT) es una osteomielitis del hueso frontal con un absceso subperióstico concomitante, principalmente secundario a sinusitis frontal complicada. Es infrecuente, pero puede tener consecuencias fatales debido a su alta asociación con complicaciones intracraneales. Presentamos el caso de una escolar de 7 años sin antecedentes, que consulta en el Servicio de Urgencia por un cuadro de 5 semanas de rinorrea mucopurulenta derecha y aumento de volumen frontal progresivo, habiendo recibido antibioticoterapia sin respuesta. Se realizan neuroimágenes que confirman el diagnóstico de rinosinusitis aguda fronto-etmoidal complicada con absceso subperióstico frontal compatible con PPT, asociado a un absceso epidural. Se manejó con antibiótico endovenoso prolongado y aseo quirúrgico mediante craniectomía por abordaje bi-coronal con drenaje de ambas colecciones y reconstrucción de base de cráneo con colgajo de pericráneo, evolucionando favorablemente. El diagnóstico del tumor inflamatorio de Pott es clínico y radiológico, siendo el aumento de volumen frontal el signo cardinal. La tomografía computarizada es útil para establecer el diagnóstico diferencial con otras entidades y la resonancia magnética permite con mayor sensibilidad y especificidad detectar complicaciones intracraneales. El tratamiento es médico y quirúrgico mediante antibioticoterapia endovenosa y aseo quirúrgico oportuno.

Pott's inflammatory tumor is an osteomyelitis of the frontal bone with a concomitant subperiosteal abscess, mainly secondary to complicated frontal sinusitis. It is rare entity but may have fatal consequences due to its high association with intracranial complications. We present the case of a healthy 7-year-old girl who presented to the emergency department with a 5-week history of mucopurulent right rhinorrhea and progressive forehead swelling without response to oral antibiotic therapy. Neuroimaging confirms the diagnosis of acute frontoethmoidal rhinosinusitis complicated with frontal subperiosteal abscess compatible with PPT and an epidural abscess. She received prolonged intravenous antibiotics for six weeks and surgical treatment with craniectomy by bi-coronal approach with drainage of both collections and reconstruction of the skull base with pericranial flap, progressing favorably. The diagnosis of Pott's inflammatory tumor is clinical and radiological. The increased frontal volume is the cardinal sign, and computed tomography is the image of choice, which is also helpful in establishing the differential diagnosis with other entities. Magnetic resonance imaging is practical, given its greater sensitivity and specificity to detect intracranial complications. Treatment is imperative and is based on adequate antibiotic therapy and prompt surgical debridement.

Pott's puffy tumor: A case report.

Key Clinical Message: Pott's puffy tumor is a rare condition primarily occurring in the younger population. This report highlights the clinical suspicion and diagnosis of Pott's puffy tumor in those presenting with favorable presentations, especially adolescents. Abstract: Pott's puffy tumor (PPT) is characterized as frontal bone subperiosteal abscess and osteomyelitis, a rare condition primarily occurring in adolescents following frontal sinusitis or head trauma. We present a case of atypical PPT in a 12-year-girl following an insect bite. The patient presented with painful forehead swelling for 4 weeks without any history of head trauma or signs of sinusitis. She had a history of a purulent pimple 2 months before presentation, following an insect bite. The primary diagnosis of PPT was made based on clinical and imaging findings. The patient was treated surgically and medically with intravenous antibiotics and had a satisfactory recovery upon the 6-month follow-up visit. This case highlights the differential diagnosis and thorough evaluation for PPT in a child with acute headache and forehead swelling, even without sinusitis symptoms.

Frontal osteomyelitis post-COVID-19 associated mucormycosis.

Rhino-orbito-cerebral mucormycosis (ROCM) is the most commonly noted form of mucormycosis, which is the most common secondary fungal infection following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Osteomyelitis is one of the rare sequelae of ROCM, frontal osteomyelitis being the rarest. We present four patients of coronavirus disease 2019 (COVID-19)-associated mucormycosis, who presented with frontal bone osteomyelitis after being treated for ROCM surgically and medically. This is the first case series highlighting this complication in post-COVID-19 mucormycosis patients and needs utmost attention as it can be life-threatening and can cause extreme facial disfiguration. All four patients are alive with salvage of the affected globe and vision being preserved in one patient. If identified early, disfiguration of face and intracranial extension can be avoided.

A 9-year-old boy with a nonmalignant forehead tumor - a rare case of pediatric Pott's puffy tumor.

BACKGROUND: Pott's puffy tumor (PPT) is a rare and potentially deadly complication of frontal sinusitis consisting of subperiosteal abscess and osteomyelitis of the frontal bone. CASE PRESENTATION: We report the case of a 9-year-old boy who presented with fever and soft tissue swelling of the forehead. Magnetic resonance imaging (MRI) depicted an abscess in the subcutaneous tissue frontally and an epidural empyema, while a cranial computed tomography (CT) scan revealed bone erosion as a sign of osteomyelitis. The patient was treated accordingly. CONCLUSIONS: This rare condition is essential to keep in mind as it needs a multidisciplinary approach and relevant imaging to start proper treatment and thus decrease the risk of intracranial complications.

A Systematic Review of Intracranial Complications in Adults with Pott Puffy Tumor over Four Decades.

The purpose of this study is to investigate the risk factors of intracranial complications in adult patients with Pott Puffy Tumor (PPT). A systematic review was conducted of clinical studies from January 1983 to December 2022 that reported on PPT adult patients. The full-text articles were reviewed for the patients' ages, sex, cultured organisms, surgical procedures, clinical sequalae, and underlying diseases that may affect the onset of intracranial complications in PPT adult patients. A total of 106 studies were included. Medical data were reviewed for 125 patients (94 males, 31 females). The median age was 45 years. A total of 52% had comorbidities, mostly head trauma (24.5%), sinus/neurosurgical operations (22.4%), immunosuppression conditions (13.3%), diabetes mellitus (9.1%), cocaine use (7.1%), or dental infections (6.1%). A total of 28 cultures revealed Streptococcus (22.4%), 24 contained staphylococci (19.2%), and 22 cultures contained other pathogens (17.6%). An amount of 30.4% developed intracranial complications, with the most common being epidural abscesses or empyemas (55.3%), as well as subdural (15.7%) and extradural lesions (13.2%). Age, DM, and immunosuppression conditions are significantly associated with intracranial complications (p < 0.001, p = 0.018 and p = 0.022, respectively). Streptococcus infection is associated with intracranial complications (p = 0.001), although Staphylococcus and other microorganisms are not. Surgical intervention, mainly ESS, and broad-spectrum antibiotics remain the cornerstones of treatment.

Pott's Puffy Tumor, a Forgotten Complication of Sinusitis: Report of Two Cases.

Pott's puffy tumor (PPT) is a life-threatening complication of infectious sinusitis/osteomyelitis of the frontal bone. It occurs due to infection or trauma and is often seen in late childhood and adolescence. If left untreated for a protracted period, intracranial complications such as epidural abscess, subdural empyema, meningitis, and a cerebral abscess may occur. The diagnosis is often confirmed with CT. Prompt medical and surgical treatment is mandatory as there is the potential for significant morbidity if not quickly diagnosed and treated. This paper presents two cases of PPT manifested in patients with hemi pansinusitis.

Pott luck.

A 10-year-old boy presented with headache, fever, left-sided ptosis, and right-sided forehead soft tissue swelling. There was no recent history of trauma or infection. The patient had a large, fluctuant mass on the right side of his forehead, upgaze restriction, left-sided ptosis, and bilateral optic disk edema. Magnetic resonance imaging of the brain showed a frontal bone extradural fluid collection superficial to the superior sagittal sinus in keeping with an epidural abscess. There were multiple venous thromboses and thickening and enhancement of the dura, compatible with meningitis. There was right sphenoid sinusitis. This patient had Potts puffy tumor, a rare diagnosis associated with a forehead swelling from frontal bone osteomyelitis and subperiosteal abscess. It is seen in the pediatric population in association with sinusitis or trauma. Antibiotics, anticoagulation, and acetazolamide were initiated, and the epidural abscess was evacuated. The symptoms and signs resolved with treatment.

Complications of frontal sinusitis. Bibliographic review

Introduction and objective: Frontal rhinosinusitis usually resolves with medical therapy. However, when the sinonasal infection persists, the anatomy of this region can lead to severe and life-threatening complications due to infection spreading beyond the sinus namely to the intracranial compartment. This review aims to highlight the more recent developments on the management of frontal rhinosinusitis and its complications, from a practical perspective that is essential to accurately diagnose these complications. Method: A review of the literature was performed by the authors. PubMed database was searched with relevant terms, which included the following: «frontal sinusitis complications», «pediatric frontal sinusitis» and «frontal sinusitis imaging». Relevant scientific treaties were also used as ancillary to this review. A comprehensive review of the English and Portuguese literature was carried out, including papers published between 2000 and 2021. Our inclusion criteria included clinical trials, expert opinion papers, literature reviews, systematic reviews and clinical guidelines. Duplicate articles, case reports or very small sample studies were excluded prior general screening. Results: Twenty-one studies met the inclusion criteria. Most of them concerned the adult population, with four papers directly addressing the pediatric population. Two clinical guidelines, one large retrospective cohort study and two systematic reviews were selected. Twelve clinical review articles and small retrospective studies were selected, comprising most of the papers addressed. Four clinical text-books were also consulted for this review. Discussion: Morbidity and mortality from complicated sinusitis are mainly related to intracranial involvement. Although the mortality rate was higher before the era of antibiotic therapy, intracranial abscess still carries high mortality. (AU)

La rinosinusitis frontal suele resolverse con tratamiento médico. Sin embargo, cuando la infección de los senos paranasales persiste, la anatomía de esta región puede dar lugar a complicaciones graves y potencialmente mortales debido a que la infección se propaga más allá del seno, es decir, al compartimento intracraneal. Esta revisión tiene como objetivo resaltar las publicaciones más recientes sobre el manejo de la rinosinusitis frontal y sus complicaciones, desde una perspectiva práctica que es esencial para diagnosticar con precisión estas complicaciones. Método: Se realizó una revisión de la literatura por parte de los autores. Se buscó en la base de datos PubMed con términos relevantes, que incluían los siguientes: «complicaciones de la sinusitis frontal», «sinusitis frontal pediátrica» y «imagen de la sinusitis frontal». Los tratados científicos pertinentes también se utilizaron como complemento de esta revisión. Se llevó a cabo una revisión de la literatura en inglés y portugués, incluidos artículos publicados entre 2000 y 2021. Nuestros criterios de inclusión incluyeron ensayos clínicos, artículos de opinión de expertos, revisiones de literatura, revisiones sistemáticas y guías clínicas. Los artículos duplicados, los informes de casos o los estudios de muestras muy pequeñas se excluyeron antes de la selección general. Resultados: Veintiún estudios cumplieron los criterios de inclusión. La mayoría de ellos se referían a la población adulta, con cuatro artículos dirigidos directamente a la población pediátrica. Se seleccionaron dos guías clínicas, un gran estudio de cohorte retrospectivo y dos revisiones sistemáticas. Se seleccionaron doce artículos de revisión clínica y pequeños estudios retrospectivos, que comprenden la mayoría de los trabajos abordados. (AU)

Unsual complications of acute frontal rhinosinusitis. Two clinical cases

Introduction: Acute frontal rhinosinusitis is defined as an acute infection of the frontal sinus. Spreading of this infection to surrounding structures is uncommon but, when present, carries signif-icant morbidity and mortality. Description: In this case report, we present two unusual cases of frontal rhinosinusitis complications. Firstly, we describe a case of acute rhinosinusitis with orbital complications caused by a frontoethmoidal osteoma. In the second case, the infection extended to the underlying bone and through the skull causing osteomyelitis and focal meningitis complicated with an abscess. After appropriate treatment, both patients were free of infection at follow-up, without complications. Discussion: In the first case we presented, a frontoethmoidal osteoma gave rise to rhinosinusitis with orbital complications. These benign tumors rarely cause symptoms, but when large enough, sinus outflow can be blocked, making the osteoma clinically relevant. Osteomas can induce frontal rhinosinusitis, giving rise, among other condi-tions, to the development of orbital complications like periorbital cellulitis or the formation of a periorbital abscess. Diagnosis of osteoma is usually straightforward on computed tomography and surgical treatment is only indicated for large tumors, rapid growth, intracranial or orbitary extension. In the second clinical case, the infection extended to the underlying bone and through the skull causing osteomyelitis and focal meningitis with abscess formation. In this patient, a Draf Type IIa procedure was performed for the frontal abscess drainage, followed by proper antibiotic and anti-inflammatory therapy. Conclusions: Complications of frontal rhinosinusitis are uncommon but require immediate attention and aggressive treatment to avoid morbidity and mortality. In these cases, our patients were properly treated with good outcomes, avoiding potentially more dangerous complications. (AU)

Introducción: La rinosinusitis frontal aguda se define como una infección aguda del seno frontal. La propagación de esta infección a las estructuras circundantes es poco común, pero, cuando está presente, conlleva una morbilidad y mortalidad significativas. Descripción: En este reporte presentamos dos casos inusuales de complicaciones de rinosinusitis frontal. En primer lugar, describimos un caso de rinosinusitis aguda con complicaciones orbitarias por osteoma frontoetmoidal. En el segundo caso, la infección se extendió al hueso subyacente y a través del cráneo causando osteomielitis y meningitis focal complicada con un absceso. Tras el tratamiento adecuado, ambos pacientes quedaron libres de infección en el seguimiento, sin complicaciones. Discusión: En el primer caso que presentamos, un osteoma frontoetmoidal dio lugar a una rinosinusitis con complicaciones orbitarias. Estos tumores benignos rara vez causan síntomas, pero cuando son lo suficientemente grandes, el flujo de salida del seno puede bloquearse, lo que hace que el osteoma sea clínicamente relevante. De hecho, los osteomas pueden inducir una rinosinusitis frontal, dando lugar, entre otras condiciones, al desarrollo de complicaciones orbitarias como celulitis periorbitaria o formación de un absceso periorbitario. El diagnóstico de osteoma suele ser sencillo mediante tomografía computarizada y el tratamiento quirúrgico solo está indicado para tumores grandes, de crecimiento rápido, con extensión intracraneal u orbitaria. En el segundo caso clínico, la infección se extendió al hueso subyacente y a través del cráneo provocando osteomielitis y meningitis focal con formación de abscesos. (AU)