A 53-year-old man with hypertension and hyperlipidemia presented with pain and swelling to the middle of his forehead that he had had for three days. The pain and swelling had grown progressively worse and were not manageable with over-the-counter ibuprofen or acetaminophen. He said he typically does not experience headaches and stated this has never happened to him before. He recalled that he did head-butt his 175-pound St. Bernard dog one day prior to the onset of the symptoms. He decided to come to the ED because his symptoms were worsening and were quite unattractive.
The patient also reported thick, yellow rhinorrhea, but denied fever, chills, photophobia, neck pain, lightheadedness, and confusion. He was a former tobacco smoker, a social drinker, and never used illicit drugs. He denied using intranasal drugs other than an occasional over-the-counter nasal spray.
The patient's vital signs were all within normal limits. His temperature was 36.4°C with a normal oxygen saturation of 99% on room air. He appeared well but had an impressive 2 cm x 3 cm x 3 cm fluctuant area to the midline of the forehead that was warm and erythematous. The area was fluctuant and tender without a puncture or drainage. The remainder of the physical examination was unremarkable.
Laboratory values for this patient were a leukocyte count of 8.95 k/ul, hemoglobin of 13.5 g/dl, platelets of 397 k/ul, glucose of 97 mg/dl, and creatinine of 1.10 mg/dl. He also had elevated C-reactive protein of 2.3 mg/dl and an elevated sedimentation rate of 60 mm/hr.
He was treated initially with IV fluids and 1 mg hydromorphone prior to CT imaging. The patient stated that his pain improved, and he returned from the CT without issues.
The surgeon pictured provides a clue.
Find the diagnosis and case discussion on next page.
Diagnosis: Pott's Puffy Tumor
The CT revealed a 1.7 cm x 3.4 cm x 3.3 cm low attenuation, peripherally enhancing subcutaneous abscess along the mid-anterior frontal bone with associated erosion of the anterior and posterior walls of the frontal sinus with opacification. There was dehiscence of the inner table, but no clear evidence of intracranial extension. Pansinusitis was also noted.
The patient appeared well throughout the ED visit, and no clinical sign of intracranial involvement was seen although the CT showed dehiscence of the inner table. IV meropenem was given and otolaryngology (ENT) consultation obtained.
Sir Percivall Pott (pictured on previous page), an English surgeon, first described this diagnosis in 1760. Today we know Pott's puffy tumor as a serious complication of bacterial frontal sinusitis, which consists of osteomyelitis and subperiosteal abscess of the frontal bone. Conditions that lead to the development of Pott's puffy tumor include trauma or fracture, longstanding acute frontal sinusitis, or chronic sinusitis that may be due to allergic polyposis or rhinitis, deviated septum, or even myxoma of the supra-orbital ridge. (Laryngoscope 1967;771234.)
Complications of Pott's puffy tumor include epidural abscess, subdural empyema, brain abscess, cortical vein thrombosis, meningitis, sagittal sinus thrombosis, cerebral edema, and death. (Pediatr Neurosurg 2001;35:82; Arch Dermatol 1985;121:548.) The most commonly identified organisms include Staphylococcus aureus, microaerophilic streptococci including alpha-hemolytic streptococcus and peptostreptococcus, and anaerobes such as Fusobacterium and mixed infections. (Pediatr Neurosurg 2001;35:82; Arch Dermatol 1985;121:548.) Initial antibiotic coverage should be broad-spectrum and include coverage of anaerobes.
A bedside nasopharyngoscopy by ENT revealed frank purulence from both osteomeatal complexes but otherwise normal. A bedside percutaneous drainage of the abscess was performed using topical Betadine, a 10cc syringe, and an 18-gauge needle. Four cc of frank pus was aspirated, and routine cultures and gram stain were sent.
The patient was admitted to the neurosurgery service, and an MRI showed no evidence of intracranial infection. It was felt that the cortical bone was still intact in the posterior table of the frontal sinus. He underwent incision and drainage of the frontal sinus abscess, frontal sinus trephination, and frontal sinusotomy as an inpatient. Intravenous antibiotics were continued, and he was discharged home after drains were removed to continue IV ampicillin plus sulbactam. The initial cultures and those obtained in the operating room isolated Streptococcus anginosus, which was pansensitive, Eikenella corrodens, and mixed anaerobic flora. Fungal cultures were negative. The patient was also treated with fluticasone nasal spray and oral methylprednisolone.
By happenstance, he was seen in the ED 14 months later for an unrelated arm injury and at that time appeared to have an excellent cosmetic outcome. The dog reportedly suffered no complication from the initial incident and is doing well.
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