Pott puffy tumor

Pranav Sharma, MD, Salil Sharma, MD, Nishant Gupta, MD, Puneet Kochar, MD, and Yogesh Kumar, MD

a b
Pott puffy tumor is osteomyelitis of the
frontal bone with associated subperiosteal
abscess causing swelling and edema over
the forehead and scalp. It is a compli-
cation of frontal sinusitis or trauma. We
present the case of an 8-year-old girl
with frontal swelling. Imaging evaluation
showed frontal osteomyelitis as a compli-
cation of frontal sinusitis with associated
epidural and subperiosteal abscess. The
patient was treated surgically and recov-
ered well. This case highlights the need
for high clinical suspicion and early diag-
Figure 1. Sagittal CT of the brain with (a) bone window and (b) soft tissue window images shows erosion of the
nosis and management to prevent life- outer and inner cortices of frontal bone (arrow) with prefrontal soft tissue swelling (arrow).
threatening complications. Unfortunately,
in our case the patient had to undergo surgery for this complication, and underwent craniotomy with trephination and drainage of
which could have been prevented by earlier diagnosis. the brain abscess. Functional endoscopic sinus surgery with a
left ethmoidectomy and frontal and maxillary antrostomy was
also performed. Culture of the pus revealed Streptococcus inter-

P
ott puffy tumor is a rare complication of sinusitis
characterized by osteomyelitis of the frontal bone with
subperiosteal abscess presenting as frontal swelling. It
was first described by Sir Percival Pott in 1768 in rela-
tion to frontal head trauma. Later, it was established that this
entity is more common in relation to frontal sinusitis (1). We
report a case of an 8-year-old girl who presented with gradually
increasing frontal swelling.
CASE REPORT
An 8-year-old girl was referred for persistent headaches
and gradually increasing frontal swelling for 3 days. She had
sinusitis 1 month earlier and was treated with azithromycin.
She had multiple drug allergies to penicillin, cephalosporin,
and cotrimoxazole. A computed tomography (CT) scan re-
vealed frontal sinusitis with cortical erosions and frontal sub-
periosteal and epidural soft tissue swelling (Figure 1). Magnetic
resonance imaging (MRI) revealed frontal sinusitis, frontal
bone defect, and frontal epidural collection with peripheral
rim enhancement suggestive of epidural abscess (Figure 2).
A small subperiosteal abscess was also noted in the frontal
soft tissues. The patient was started on intravenous antibiotics
medius. The follow-up MRI revealed resolution of subperiosteal
and epidural abscesses (Figure 3).
DISCUSSION
Pott puffy tumor is a rare clinical entity with the advance-
ment in antibiotic treatment. Initially described with head
trauma, now it is known to be associated with untreated or
partially treated sinusitis; however, cases due to mastoid surgery,
dental infections, wrestling injuries, and insect bites have been
reported (2, 3). Pott puffy tumor can be found in all age groups,
but occurs predominantly in adolescents (4). Frontal sinuses
are often pneumatized by 2 years of age and are approximate
adult size by the late teens. Venous drainage occurs through
diploic veins that have communication with the dural venous
sinuses, which can propagate septic emboli (4). These infections
From the Department of Radiology, Yale New Haven Health at Bridgeport Hospital,
Bridgeport, Connecticut (P. Sharma, S. Sharma, Kochar, Kumar); and the Department
of Radiology, St. Vincent’s Medical Center, Bridgeport, Connecticut (Gupta).
Corresponding author: Yogesh Kumar, MD, Department of Radiology, Yale New
Haven Health at Bridgeport Hospital, 267 Grant Street, Bridgeport, CT 06610
(e-mail: yogeshkumar102@gmail.com).

Proc (Bayl Univ Med Cent) 2017;30(2):179–181 179

 a b reduction. A CT scan with contrast
can be performed if there is a high
suspicion of intracranial extension.
Intracranial complications with or
without direct erosion of the frontal
bone have been observed in about
60% to 85% of these patients (5,
7). Tsai et al reported a 100% rate
of intracranial complications in their
six pediatric patients with Pott puffy
tumor (8). Ketenci et al indicated
that intracranial complications are
often present during a regimen of
antibiotics and are often asympto-
matic when the abscess is localized
Figure 2. (a) Sagittal T2 fluid-attenuated inversion recovery and (b) axial contrast-enhanced T1-weighted images in a silent area of the central nervous
show frontal sinusitis (smaller arrow), frontal bone defect (curved arrow), and frontal epidural collection (longer system (5, 9, 10).
arrow) with peripheral rim enhancement (larger double arrows) suggestive of epidural abscess. A small subperiosteal
CT scan can demonstrate si-
abscess is also noted in the frontal soft tissues (smaller double arrows).
nusitis, bone erosion, subperiosteal
collection, and intracranial exten-
are often polymicrobial, with streptococci, staphylococci, and sion. In our case, CT showed frontal sinusitis, bone erosion,
anaerobic bacteria, as they favor lower oxygen concentrations. subperiosteal collection, and extradural abscess. As with other
Hence, antibiotic coverage should include gram-positive and intracranial pathologies, MRI is the modality of choice (11, 12).
anaerobes (5). In the present case, the organism was Streptococcus MRI can better delineate intracranial pathology, dural sinus
intermedius. thrombosis, and bone edema. Abscesses show restricted diffu-
Symptoms include headache, periorbital swelling, fever, sion (13, 14) on diffusion-weighted sequences, indicating thick
purulent rhinorrhea, vomiting, and signs of meningitis or en- viscous pus. In this case, MRI showed frontal bone edema and
cephalitis. Intracranial complications occur either due to direct extradural abscess, without dural venous sinus or meningeal in-
extension or venous drainage. Complications include meningi- volvement. MRI is helpful particularly in follow-up after medi-
tis; epidural, subdural, or intraparenchymal abscess; and cavern- cal or surgical management, reducing overall radiation exposure.
ous sinus and dural venous sinus thrombosis (5). If the inferior Bone scintigraphy with Tc-mMP may be more sensitive than
wall of the frontal sinus is involved, infection may spread to the CT in detection of early osteomyelitis, but its sensitivity is poor
orbits, causing either orbital cellulitis or intraorbital abscess (6). in the setting of acute sinusitis (15).
Our patient presented with frontal swelling and headache Early diagnosis and treatment of Pott puffy tumor is neces-
in the emergency department and received a CT. Although sary. Broad-spectrum antibiotics for 4 to 6 weeks, along with
CT scans have a higher radiation dose, at most centers like surgical drainage, is the standard of care. This patient underwent
ours, MRI scanners are not available around the clock. Par- frontal craniotomy and functional endoscopic sinus surgery
ticular attention should be paid to decrease the radiation dose in addition to 4 weeks of antibiotics. Follow-up MRI showed
by strictly following the pediatric protocols for radiation dose complete resolution.

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