Pott’s Puffy Tumour

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Pott’s Puffy Tumour


Disease Entity

Disease

Pott’s Puffy Tumor is one of the most dangerous complications of frontal sinusitis, and is characterised by osteomyelitis of the frontal bone with an associated subperiosteal abscess.[1][2][3]

It was first described by Sir Percival Pott in 1768.

Epidemiology

Pott’s Puffy Tumor is now a rare pathology due to advances in antibiotic treatment of sinusitis. [4]

It can occur in all ages but shows predilection for adolescents due to increased vascularization in diploic circulation of the frontal sinus in this age, which allows a faster spread of infection.

Globally, males are affected more frequently (3,5:1) but there is no evidence for racial predication.[3][4][5]

Physiopathology

Chronic sinusitis is associated with several intra and extracranial complications, namely pre-septal and post-septal cellulitis, intracranial abscess or meningitis, Pott’s Puffy Tumor and cavernous sinus thrombosis.[2]

Pott’s Puffy Tumor was initially thought to be associated with frontal head trauma. Now it is known to be secondary to untreated or partially treated sinusitis and in extremely rare cases due to mastoid surgery, dental infections, wrestling injuries, and insect bites.[3][4]

The etiological agents most frequently associated with this infection are Streptococcus, Staphylococcus, Enterococcus, Bacteroides sp and anaerobic bacteria. Nevertheless, these infections are often polymicrobial and antibiotic coverage should include gram-positive and anaerobes.[3][4][5]

Diagnosis

Clinical Evaluation

Symptoms include frontal scalp and periorbital swelling, fever, purulent rhinorrhoea, photophobia, frontal sinus tenderness, vomiting, and signs of meningitis or encephalitis.[2][4]

Pott’s Puffy Tumor can lead to life-threatening complications. In 85% of patients, Pott’s Puffy Tumor is a predictor of intracranial complications such as meningitis, cavernous sinus and dural venous sinus thrombosis, orbital cellulitis with or without intraorbital abscess (if the inferior wall of the frontal sinus is involved) and epidural, subdural or intraparenchymal abscesses. The spread of the infection can occur either due to direct extension by erosion of frontal sinus walls or by migration of septic thrombi through the diploic veins.[2][3][4][5]

Imaging

The imaging modality of choice to confirm the diagnosis is a computed tomography (CT) scan that can evidence frontal sinusitis, bone erosion, subperiosteal collection, and extradural abscess.[4][5]

Magnetic resonance imaging (MRI) is the gold standard to detect the presence of intracranial complications as intracranial abscesses and dural sinus thrombosis. Since MRI is a method with absence of radiation, it is useful in follow-up after medical or surgical management.[2][4][5]

Management

Treatment

The treatment goal of Pott's Puffy Tumor is to prevent its progression to life-threatening intracranial complications.

A close collaboration between otorhinolaryngologists, neurosurgeons and ophthalmologists is necessary for appropriate and life-saving management of patients with this pathology.[6]

The standard of care is intravenous broad-spectrum antibiotics with good penetration in CNS and anaerobic coverture for 4 to 6 weeks (clindamycin, ceftriaxone, metronidazole, vancomycin), along with surgical treatment as drainage of subperiosteal abscess, eradication of potential infection in sinuses, and treatment of possible intracranial complications.[4][5][6] Imaging follow-up should be performed with MRI.

Prognosis

Pott’s Puffy Tumor is a predictor of a potentially life-threatening infection and it is associated with high mortality and morbidity.

The mortality rate of around 12% is usually due to increased intracranial pressure, thrombosis, ischemia and sepsis. Neurological deficits condition considerable long-term morbidity.[2][5]

References

  1. Rajwani KM, Desai K, Lew-Gor S. Forehead swelling and frontal headache: Pott's puffy tumour. BMJ Case Rep. 2014;2014:bcr2013202737. Published 2014 Jan 16. doi:10.1136/bcr-2013-202737
  2. 2.0 2.1 2.2 2.3 2.4 2.5 Terui H. et al, Pott’s Puffy Tumor Caused by Chronic SinusitisResulting in Sinocutaneous Fistula. JAMA Dermatology. 2015. 151:11
  3. 3.0 3.1 3.2 3.3 3.4 Tatsumi S., et al, Pott's Puffy Tumor in an Adult: A Case Report and Review of Literature. Journal of Nippon Medical School. 2016. 83: 211-214
  4. 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 Sharma P, Sharma S, Gupta N, Kochar P, Kumar Y. Pott puffy tumor. Proc (Bayl Univ Med Cent) 2017;30:179–181.
  5. 5.0 5.1 5.2 5.3 5.4 5.5 5.6 Koltsidopoulos, P. , Papageorgiou, E. and Skoulakis, C. Pott's puffy tumor in children: A review of the literature. The Laryngoscope. 2019
  6. 6.0 6.1 Liliana Costa et al, Pott's puffy tumor: rare complication of sinusitis, Brazilian Journal of Otorhinolaryngology, 201