Pott's Puffy Tumor: A Rare but Important Complication of Sinusitis

1Washington University, St. Louis, MO
2Washington University, St. Louis, St. Louis, MO

Meeting: Hospital Medicine 2011, May 10-13, Dallas, Texas.

Abstract number: 340

Case Presentation:

This is an 11‐year‐old male who was well until 3 days prior to admission, when he developed nasal congestion, fever, and a tender swelling of the forehead. The patient's medical history was significant for autism, with decreased ability to communicate pain. On exam, the patient was febrile, and other vital signs were within normal limits. He was alert and interactive. His head and neck exam showed a tender swelling on the forehead that was 3 cm in diameter and was nonerythematous. Laboratory investigations showed an elevated white blood cell count and a blood culture that grew goup A Streptococcus. A lumbar puncture showed normal values. The patient was started on ceftriaxone and clindamycin. A CT scan showed frontal sinusitis and a subperiosteal fluid collection that was 3 × 18 mm, confirming the diagnosis of Pott's Puffy Tumor. Otolaryngology evaluated the patient and elected to treat medically. The patient defervesced but developed worsening headache and emesis. An MRI was then obtained and revealed a subperiosteal fluid collection that had enlarged to 5 × 26 mm in size as well as a subdural empyema that was 3 × 10 mm. Otolaryngology drained 2 mL of purulent fluid from the subperiosteal fluid collection, which did not yield an organism. The patient rapidly improved after this surgery and was sent home to complete a 4‐ to 6‐week course of antibiotics via a peripherally inserted central catheter.

Discussion:

Named for Sir Percival Pott (1713–1788), Pott's puffy tumor (PPT) is a serious complication of bacterial frontal sinusitis. PPT is a rare entity in the postantibiotic era. Although sinusitis is the most frequent precipitant, PPT has also been described following mastoiditis and trauma. Patients typically present with fever, headache, and local swelling of the forehead. PPT has been associated with a variety of pathogens including Streptococcus milleri, Haemophilus influenzae, Streptococcus pneumoniae, Staphlococcus aureus, and various anaerobes. Complications from PPT include sinus thrombosis, subdural empyema, meningitis, and brain abscess. Venous spread of infection through the valveless diploic veins is the most likely route for extension of infection. Treatment typically combines a combination of medical and surgical approaches. Empiric antibiotic coverage should include agents with gram‐positive, gram‐negative, and anaerobic coverage. Because PPT is by definition osteomyelitis of the frontal bone, a 4‐ to 6‐week course of antibiotic therapy is recommended.

Conclusions:

In conclusion, we report a case of PPT in a child with autism who may have had delayed therapy because of his decreased ability to express pain. This should remind the clinician to have a lower threshold for imaging in a patient with subtle evidence of sinusitis and an impaired ability to communicate. This case also illustrates a patient with a PPT who developed a subdural empyema, a previously reported yet still unusual complication of PPT.

Disclosures:

A. S. Miller ‐ none; R. J. Osguthorpe ‐ none; P. M. Kilbridge ‐ none

To cite this abstract:

Miller A, Osguthorpe R, Kilbridge P. Pott's Puffy Tumor: A Rare but Important Complication of Sinusitis. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 340. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/potts-puffy-tumor-a-rare-but-important-complication-of-sinusitis/. Accessed November 18, 2019.

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