Physical findingPott's Puffy Tumor
Section snippets
Clinical Scenario
A 16-year-old boy presented with swelling of his forehead. He had been well until 4 months previously when he had the first of 3 episodes of sinusitis. He was treated with short courses (generally 1 week) of antibiotics for each of these episodes. He continued to have frontal headache on and off over these 4 months. About 1 week before admission, his mother noted a lump in the middle of his forehead. This increased in size over a few days and lead to his admission (Figure). The admitting
Features of Pott's Puffy Tumor
Pott's puffy tumor is actually frontal osteomyelitis accompanied by a subperiosteal abscess of the frontal bone. This “puffy” lesion arises when infection breaks through the outer table of the frontal bone to form an abscess between bone and periosteum. It remains “circumscribed” because of tight adherence between periosteum and bone.
Pathophysiology
Pott's puffy tumor is often associated with antecedent sinusitis and less commonly with trauma.2 Pott's puffy tumor and its complications are a result of the unique configuration of the frontal sinuses and their vascular structures. The diploic veins drain the frontal sinuses. These thin-walled, valveless vessels facilitate hematogenous spread of sinus infection to bone and brain.3, 4 The usual route for infection spread is from the frontal sinus to the frontal bone. The infection may further
Epidemiology
The incidence has decreased significantly in the post-antibiotic era. Although articles on Pott's puffy tumor are rare, many speculate that it is more common than the literature would suggest.9 This entity is seen more frequently in adolescents and young adults, likely because adolescence corresponds with a peak in the vascularity of the diploic system and growth of the frontal sinus.10, 11 Despite antimicrobial therapy, the mortality rate is 5%-10%.4
Symptoms Associated with the Physical Sign
Symptoms are often indolent, including headache and little or no fever. Increasing symptoms suggest complications. Although a history of sinusitis or trauma is helpful, absence of this history does not rule out Pott's puffy tumor.
Approach
Early diagnosis is critical to prevent complications.12 Image with computed axial tomography scan or magnetic resonance imaging to define the extent of the infection.13 A combined approach is suggested, with 6 weeks of antimicrobials and surgery. Antimicrobial therapy should be tailored to the organisms isolated from surgical specimens.12 Surgery might consist of abscess drainage, bony debridement, and trephination of the frontal sinus.14
References (14)
Observations on the Nature of Consequences of Wounds and Contusions of the Head, Fractures of the Skull, Concussions of the Brain
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Osteomyelitis of the frontal bone
Laryngoscope
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Pott's puffy tumor: a clinical variant
Aust NZ J Surg
(1999) - et al.
Intracranial complications of acute frontal sinusitis
Clin Otolaryngol
(2001) - et al.
Pott's puffy tumor following an insect bite
J Postgrad Med
(2007) - et al.
Pott's puffy tumor, frontal sinusitis, frontal bone osteomyelitis and epidural abscess secondary to a wrestling injury
Am J Sports Med
(1981) - et al.
Pott's puffy tumor: a complication of intranasal cocaine abuse
Rev Infect Dis
(1991)