Life is complex and even the common can become complicated. Yes, “simple viruses” can wreck havoc (COVID is certainly reminding us of this now… but let’s not forget Measles and Mumps and Varicella to name a few). Sure pneumonia is bad, but it can become complicated too (Parapneumonic Effusion). Recently, a brilliant colleague of ours, Dr. Simone Lawson, reminded me of another seemingly simple condition that can go array. We have discussed sinusitis previously, but let’s turn our attention to one of its complications- Pott’s Puffy Tumor:

Pott’s Puffy Tumor: Basics

• First described and named for surgeon, Sir Percivall Pott (1714-1788) in 1760.
  • Same physician who described the destructive tuberculosis spinal body infection.
  • Pott’s Fracture (term once used for bimalleolar ankle fractures) was also named after him.
  • Yes, back in the day, when nothing was named… you got to your name on everything!

• Pott’s Puffy Tumor is Forehead Swelling due to Subperiosteal Edema / Abscess / Granulation tissue. [Palabiyik, 2016; Blumfield, 2011]
  • Typical results from frontal bone osteomyelitis.
  • Has been considered “rare” in the post-antibiotic era. [Tsai, 2010]
  • It has, however, been reported at a greater rate recently. [Blumfield, 2011; Tsai, 2010]

• Anatomy Matters: [Palabiyik, 2016; Blumfield, 2011; Tsai, 2010]
  • Adolescents are most often affected due to anatomic changes.
    • Mean age of one study = 13 years and 3 months [Tsai, 2010]
    • Frontal sinus completes its development during pre-teen ages.
      • Frontal sinuses begin being to develop between 2 – 10 years of age.
      • Frontal sinuses don’t reach the orbital ridges until ~ 6 years of age.
    • The diploic circulation is at its peak during adolescence.
      • Diploic veins are thin-walled and valveless veins.
      • They are between the inner and outer layers of cortical bone of the skull.
      • In the frontal bone, they drain blood from the frontal sinus mucosa, marrow cavity, and bone.
      • Allows for a regional infection to spread more easily, both to superficial areas and deep regions.
  • The infection can spread anteriorly (into the frontal bone subperiosteum and overlying soft tissues), posteriorly (into the intracranial space), and/or inferiorly (into the orbital spaces).

• Complications of Pott’s Puffy Tumor can be: [Tsai, 2010]
  • Orbital Cellulitis
  • Periorbital Cellulitis
  • Intracranial Abscess / Infection
    • Epidural Abscess
    • Subdural Abscess / Empyema
    • Cerebral Abscess
    • Meningitis
  • Vascular Complications
    • Cavernous sinus thrombosis
    • Superior sagittal sinus thrombosis
  • Mortality rate was once as high as 60%… now ~3%.

Pott’s Puffy Tumor: Evaluation

• Risk factors associated with developing Pott’s Puffy Tumor are: [Blumfield, 2011; Tsai, 2010]
  • Acute sinusitis
    • Atypical presentation of frontal sinusitis may lead to delayed diagnosis.
    • Frontal sinusitis may lack nasal symptoms and have only headache.
  • Chronic sinusitis
  • Recent head/facial trauma
  • Iatrogenic (post surgical)

• Presentation: [Palabiyik, 2016; Tsai, 2010]
  • Fever, Headache, and Frontal Swelling are the most common findings.
    • Frontal swelling can include the upper eyelids.
    • Forehead is typically tender, but overt redness may not be seen.
  • Other associated symptoms:
    • Vomiting / nausea
    • Fatigue / malaise
    • Purulent rhinorrhea
    • Periorbital Swelling
    • Proptosis
    • Evidence of Intracranial extension:
      • Seizure
      • Focal weakness, Aphasia
      • Altered mental status
      • Shock
  • Often diagnosed after an average of 7 days of fever!
    • Initial presentation may not be specific.
    • Unfortunately, delayed presentation and diagnosis may lead to increased complications.
    • Most have intracranial involvement upon diagnosis.

• Imaging:
  • Contrast Enhanced CT [Blumfield, 2011]
    • CT with contrast is the 1st imaging modality.
    • Noncontrast head CT does not give enough information.
    • Contrast Enhanced CT of the brain shows bone well and can demonstrate whether there is intracranial extension.
  • MRI and MRV [Blumfield, 2011]
    • MRI should be obtained once patient has been stabilized.
    • MRI is superior to CT when evaluating the intracranial complications.
    • It can detect smaller foci of infections.
    • MRV can evaluate the cavernous and dural sinuses for thrombosis as well.

• Management: [Palabiyik, 2016; Tsai, 2010]
  • Broad Spectrum Antibiotics!
    • Relatively low oxygen concentration in the frontal sinuses is a nice environment for many bad bugs!
      • Strep species, Bacteroides species, Bacteroides species, Anaerobes!
      • May be “Sterile” in cases where patients have been on antibiotics recently.
      • Often polymicrobial!
    • Antibiotics are typically continued for ~6-8 weeks post-operatively.
    • Consultation with Infectious Disease is often warranted.
  • Drainage
    • Consultation with ENT and Neurosurgery is needed.
    • May be amenable to endoscopic procedures, but may also require open interventions.

Moral of the Morsel

• It’s not gone, so don’t let it be forgotten! Pott’s Puffy Tumor is still an entity that can develop and needs to remain on our Ddx lists.
• Not all sinusitis has rhinorrhea and nasal congestion! That severe forehead pain may be the only early clue to frontal sinusitis developing into osteomyelitis.
• Forehead Swelling? Yeah, that ain’t normal! Unfortunately, by the time this develops, the likelihood of other local extension is high. Get that CT with Contrast first!

References