A Rare Complication of Frontal Sinusitis: Pott's Puffy Tumor

Pott's Puffy Tumor (Frontal Osteomyelitis)

Complication of Frontal Sinusitis: Pott's Puffy Tumor

Definition of Pott's Puffy Tumor

Pott's puffy tumor is a rare clinical entity characterized by subperiostal abscess associated with osteomyelitis. It is often seen as a complication of frontal sinusitis or trauma. Complications of paranasal sinus disease are often encountered in pediatric otolaryngology practice and often respond to conservative treatment, including treatment against appropriate antimicrobial agents.Sometimes, complications can occur despite aggressive antibiotictherapy. An unusual but important complication of frontal sinusitis is Pott’s puffy tumor. Pott’s puffy tumor is not a real neoplasm, but it can occur as anterior and posterior extension of the purulent material in the frontal bone as a result of sinusitis spreading to the frontal bone. Pott's puffy tumor is a rare condition in children and adolescents, rarely seen in adults. In the literature of the postantibiotic period, only 20-25 cases were seen in the adolescent age group. Pott puffy tumor may be associated with cortical vein thrombosis, epidural abscess, subdural empyema and cerebral brain abscess. As previously mentioned, the most common microaerophilic streptococci in cultures, including alpha-hemolytic streptococcus, Peptostreptococcus, Bacteroides species and the like, are other Fusobacterium anaerobes. These organisms are more common in this environment compared to other autorhinological infections associated with lower oxygen concentration due to ostial hole obstruction in the frontal sinus. malignant and benign tumors should be differentiated. If a Potts puffy tumor is diagnosed, appropriate imaging (CT or Magnetic resonance imaging) should be requested (to evaluate complications) (epidural, subdural, and brain abscess). There are two major complications of paranasal sinus disease are common postseptal cellulitis and less common Potts puffy tumor.

The paranasal sinus tomography showed an inflammatory formation that completely filled the frontal sinus. The anterior wall of the frontal sinus was found to be in the destritis. Endoscopic and frontal sinus drainage was planned by external approach and frontal sinus surgery.

Causes of Pott's Puffy Tumor

First described by Sir Pervical Pott in 1768, "Pott's Puffy Tumor" is a subperiostal abscess following frontal sinusitis with osteomyelitis of the frontal bone, and it has become rare in recent years with the regular use of antibiotic treatments. However, it may be associated with other purulent intracranial complications such as epidural, subdural or frontal lobe abscess. Although it is generally seen as a complication of acute or chronic frontal sinusitis, it may also be due to frontal bone trauma, intranasal cocaine use, fungal infection, history of cranioplasty, insect bite, acupuncture or frontal sinus mucocele. Typical clinical findings include headache, periorbital edema, purulent nasal discharge, fever and nausea. This complication can be seen in all age groups in children and is more common in adolescents. Epidural abscess, meningitis, subdural empyema, brain parenchymal abscess, venous thrombophlebitis are among other supurative intracranial complications that may occur due to frontal sinusitis. Complications are caused by direct spread of infection or venous drainage of the frontal sinus.

Typical clinical findings include headache, periorbital edema, purulent nasal discharge, fever and nausea. This complication, which can be seen in all age groups, is more common in children and adolescents.

Epidural abscess, meningitis, subdural empyema, brain parenchymal abscess, venous thrombophlebitis are among other supurative intracranial complications that may occur due to frontal sinusitis. Complications of direct spread of infection or venous frontal sinus
drainage.

Pott's Puffy Tumor Symptoms

Typical clinical signs headache, forehead or periorbital swelling, purulent nasal discharge, fever and vomiting. The most common symptom in intracranial abscess formation is headache. Symptoms such as nausea-vomiting, lethargy, and focal neurological findings, which may be associated with increased intracranial pressure, are also frequently associated with headache.

Although the patient had a headache and swelling of the scalp, which was typical clinical findings of Pott tipiks puffy tumor, there was no fever due to parenteral antibiotic treatment initiated at the external center. Symptoms of intracranial complications occurred in the following days.

Pott's Puffy Tumor Diagnosis

Although there is no typical or diagnostic laboratory finding in intracranial complications due to frontal sinusitis, leukocytosis, high erythrocyte sedimentation rate and CRP elevation may be seen. The diagnosis is made by contrast computed tomography (CT). Contrast-enhanced cranial magnetic resonance imaging (MRI) should also be performed in case of suspicion of additional intracranial complications.

Although it is a rare complication, Potts puffy tumor should be strongly suspected in cases with fluctuation / erythematous swelling of the scalp because of its serious morbidity. Although there is no specific finding in the laboratory, erythrocyte sedimentation rate and leukocytosis can be seen.

Diagnosis is made by contrast computed tomography. In the case shown here, Potts puffy tumor was diagnosed by CT; central nervous system infection and abscess were diagnosed by contrast-enhanced MRI/

Pott's Puffy Tumor Differential Diagnosis

Differential diagnosis includes skin soft tissue infections, hematoma, malignant and benign tumors of the skin.

Complication of Frontal Sinusitis: Pott's Puffy Tumor

Pott's Puffy Tumor (Frontal osteomyelitis) Treatment

Medical therapy with broad-spectrum intravenous antibiotics and early surgical intervention constitute the basis of this complication.

Parenteral broad-spectrum antibiotic therapy and concurrent surgical intervention are the main approaches in the treatment of this complication. The frontal sinus according to the severity of the disease and the preference of the surgeon in surgical treatment
Different techniques can be used either alone or in combination, including trefination, craniotomy, frontal sinus obliteration or frontal sinus endoscopic sinusotomy.

Treatment consists of drainage of the abscess, excision of the necrotic tissue and the use of parenteral antibiotics depending on the pathogen. In endoscopic surgery, the entire frontal sinus should be seen and the entire pathological mucosa should be cleared. Frontal sinus obliteration is recommended. The obliteration materials may be synthetic, such as hydroxyapatite cement, or may consist of natural structures such as bone, fat or cartilage. Hydroxyapatite cement is safe and effective for frontal sinus obliteration and reconstruction of frontal sinus defects. This technique has minimal morbidity and can provide complete osteointegration. Nasal vasoconstrictors and mucolytics are important in treatment. Pott's puffy tumor may be more complicated by potential fatal intracranial spread (extradural or subdural empyema), such as cerebral abscess and / or cerebral vein thrombosis. Intracranial complications are seen in 60-85% of Pott’s puffy tumors.

Summary About "Pott's Puffy Tumor"

A rare complication of Pott’s Puffy tumor due to acute / chronic frontal sinusitis may lead to delay in diagnosis. Early diagnosis is important to prevent fatal complications in these patients. In order to diagnose this disease, it is important to suspect clinically. While definitive diagnosis is made by clinical findings and imaging methods, early initiation of appropriate treatment is essential to avoid serious complications.

Complication of Frontal Sinusitis: Pott's Puffy Tumor

A rare complication of Pott’s Puffy tumor due to acute / chronic frontal sinusitis may lead to delay in diagnosis. Early diagnosis is important to prevent fatal complications in these patients. The most common findings in Pott’s puffy tumor, a complication of acute / chronic frontal sinusitis, are more common in children and adolescents. headache, periorbital edema, nausea and swelling of the forehead. Surgical and medical treatment should be combined in this tumor which is a risk factor for intracranial complications such as subdural abscess and brain abscess. In order to avoid long-term neurological complications, it is particularly important to start appropriate antibiotic therapy in the early period. Early diagnosis and treatment of recurrence requires close clinical and radiological follow-up.

Similar link >> Endoscopic Sinus Surgery / Sinusitis - Definition, Symptoms, Causes, Complications and Treatment

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Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon - ENT Doctor in Istanbul

Private Office:
Address: İncirli Cad. No:41, Kat:4 (Dilek Patisserie Building), Postal code: 34147, Bakırköy - İstanbul
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