Patient Presentation
A 13-year-old female was referred with a history of headache, fever and swelling of her forehead for 24 hours after a few day history of rhinorrhea and nasal congestion. She was seen by an outside emergency room, started on antibiotics and referred for surgical treatment after the original computed tomographic study showed a frontal bone abscess. The past medical history was positive for otitis media as a younger child, and strep throat in the past. The family history was non-contributory.

The pertinent physical exam showed an ill-appearing female with a temperature of 101.9F, pulse of 96/minute, respiration of 22/minute with a normal blood pressure and growth parameters. She had midline forehead swelling with tenderness of the area. There were no other masses on her head. She had bilateral eyelid edema, but her pupils were equal and reactive, with normal extra ocular movements. Her nose had copious rhinorrhea bilaterally that was also seen in the posterior pharynx. Tonsils were 2+ and symmetric as was the uvula. Her neck had full range of motion and there were shotty anterior cervical nodes. Neurological examination showed normal mentation but the patient was in some pain. She had normal cranial nerves and the rest of her neurological and general examination was normal.

The diagnosis of Pott’s puffy tumor was made. The radiologic evaluation is shown below. The patient’s clinical course over the next several days included surgical drainage and antibiotics. The patient was discharged home on day 8 with home antibiotics for a planned minimum of 6-8 weeks.

Sagittal CT with contrast of the brain shows complete opacification of the frontal sinus due to sinusitus (above left) and erosion of the inferior wall of the frontal sinus (above right) along with soft tissue swelling anterior to the left orbit. Coronal and sagittal T1 MRI with contrast of the brain shows multiple oval low intensity lesions in the left subgaleal tissues which are subcutaneous abscesses and multiple enhancing fluid collections in the subdural space along both cerebral convexities and the falx in the midline which is subdural empyema.

Discussion
Pott’s puffy tumor (PPT) was first described by Sir Percivall Pott in 1775 and who also described other orthopaedic and oncological diseases subsequently named for him. “It is a subperiosteal abscess of the anterior wall of the frontal sinus associated with underlying frontal osteomyelitis.” The tender edema and swelling of the forehead is the sign of PPT. Associated fever, headache, and rhinorrhea along with similar problems such as postnasal drip or nasal congestion are common. Associated ophthalmological problems include peri-orbital or eyelid edema and/or preseptal cellulitis. Ptosis and diplopia have also occurred. In a study of PPT ophthalmological complications, 72% of patients with ophthalmological problems also have intracranial complications.

In a 2020 review of the literature in children identified 93 cases. Sinusitis (79%) was the main cause with head trauma (8.7%) being another major cause. Other causes not discussed in this review include dental infections, surgical complications, substance abuse, mastoiditis, and fibrous dysplasia. The pathogens were often not identified (presumably because of pretreatment with antibiotics) but often had multiple organisms. Of single organisms, Streptococcus and Staphlococcus predominated. Epidural abscess (47%), subdural abscess (25%) and brain abscess (12%) were the most common intracranial complications, but cerebritis, fistula, pneumocephalus and superior sagittal sinus thrombosis also occurred.

The PPT infection is spread directly or hematogenously. “Direct extension…through posterior wall causing intracranial pathology, through the anterior wall results in in subperiosteal abscess, and/or through the inferior wall with orbital complications.” Septic emboli are believed to spread hematogenously through the thin walled diploic veins that drain the frontal sinuses and which “…communicate with the dural venous plexus and periosteum of the periorbital and cranial spaces.” Evaluation with radiologic imaging such as computed tomography or magnetic resonance imaging helps with diagnosis, determining the extent of the infection and complications and with surgical planning. Although prolonged antibiotic courses are important for management, surgical intervention to drain the abscess and debride the tissues such as bone and granulation tissue are the mainstay. Neurosurgical intervention for treatment of intracranial pathology when present is also a mainstay of management.

Learning Point
PPT occurs in all ages and is rarer in the antibiotic era but it appears that there are more cases being reported recently. There is a higher incidence in adolescence. In the 2020 review discussed above, the age ranged from 7 weeks to 19 years. Mean age was 11.94 years. 70% were male and 30% were female.

The review authors explain that the increased incidence during adolescence is probably due to anatomy as the diploic veins have increased blood flow, the frontal sinuses and bone-marrow spaces are less tight in adolescents compared with adults and the pneumatization of the frontal sinuses is finally finished by around 14-15 years of age.

Questions for Further Discussion
1. Explain the differences between brain, subdural and epidural abscesses?
2. Name some conditions that warrant emergency treatment by an otolaryngologist?

Related Cases

Disease: Pott’s Puffy Tumor | Abscesses

Symptom/Presentation: Fever and Fever of Unknown Origin | Mass or Swelling | Rhinitis

Specialty: Infectious Diseases | Medical History | Neurology / Neurosurgery | Otolaryngology | Radiology / Nuclear Medicine / Radiation Oncology

Age: Teenager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Abscess

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Parida PK, Surianarayanan G, Ganeshan S, Saxena SK. Pott’s puffy tumor in pediatric age group: a retrospective study. Int J Pediatr Otorhinolaryngol. 2012;76(9):1274-1277. doi:10.1016/j.ijporl.2012.05.018

Nisa L, Landis BN, Giger R. Orbital involvement in Pott’s puffy tumor: a systematic review of published cases. Am J Rhinol Allergy. 2012;26(2):e63-70. doi:10.2500/ajra.2012.26.3746

Koltsidopoulos P, Papageorgiou E, Skoulakis C. Pott’s puffy tumor in children: A review of the literature. Laryngoscope. 2020;130(1):225-231. doi:10.1002/lary.27757

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa