CASE 12557 Published on 20.03.2015

Pott\'s puffy tumour

Section

Head & neck imaging

Case Type

Clinical Cases

Authors

Carmen Salvan-Schaschl¹, Dennis Bohlsen²

(1) Division of General Radiology,
Department of Radiology,
Medical University of Graz, Austria
(2) Division of Neuroradiology,
Department of Radiology,
Medical University of Graz, Austria

Patient

11 years, male

Categories

Area of Interest Head and neck ; Imaging Technique CT, MR

Procedure Diagnostic procedure ; Special Focus Inflammation, Infection, Abscess ;

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Clinical History

11-year-old male patient presenting with frontal pain and swelling, occurring after a head trauma during a football game in the week before. The anamnesis revealed a history of treated sinusitis two months ago, with mild residual rhinorrhoea.

Imaging Findings

The clinician suspected a fracture and requested a CT examination. The examination showed subtotal obliteration of the maxillary sinus bilaterally, as well as of the ethmoidal cells and of the left frontal sinus, interpreted as sinusitis (Fig. 1, 2), accompanied by an approximately 1.5x1.3 cm large destruction/osteolysis of the left frontal bone suggesting an osteomyelitis (Fig. 3, 4). A periosteal reaction of the wall of the maxillary sinus (Fig. 2) was observed, indicating chronic inflammatory disease. At the left frontal sinus an extra-axial (epidural) lesion (approx. 1.7x1 cm) suspected to be an abscess with impression of the frontal grey matter, and a subcutaneous swelling (Fig. 5) were seen. Further, for complete characterization and evaluation of the extent of the disease an enhanced MRI examination was performed, confirming the initial interpretation. A subperiostal abscess of the forehead and an epidural abscess were diagnosed (Fig. 6, 7, 8). No cerebral involvement was detected. The patient underwent surgical treatment in addition to antibiotics.

Discussion

Pott’s puffy tumour is a rare condition in the antibiotic era, characterized by osteomyelitis of the frontal bone and subperiosteal abscess [1, 2, 3, 4, 5, 6, 7] as shown in this case. Usually it is a complication of acute or chronic sinusitis or trauma [1, 3, 5, 6, 7, 8, 9, 10, 11], seldom of acupuncture therapy [4] or postinterventional. (The anamnesis revealed in this case both possibilities - trauma and sinusitis - but sometimes one is misleading.) Pott's puffy tumour is more often diagnosed in men [1, 3, 4, 5, 7, 8, 9, 10] and paediatric or adolescent patients [1, 3, 4, 6, 8, 9, 11]. However, it occurs in adult patients, too [2, 5, 7, 10]. Presenting symptoms include swelling of the forehead, headache, fever, rhinorrhoea, vomiting, fatigue, and sometimes patients are asymptomatic [1, 3, 4, 6, 8, 9]. Complications of Pott’s puffy tumour are epidural abscess, subdural empyema, brain abscess, cortical vein thrombosis, focal meningitis, orbital cellulitis [1, 3, 4, 6, 9, 11]. CT examination, especially if enhanced, reveals the pathology, which is sinusitis with opacification and obliteration of the sinus, defects with osteolysis of the frontal bone and/or the other previously described aspects and subperiosteal abscess [2, 3, 4, 8, 9, 10, 11]. Conventional radiography is obsolete in characterizing the extent of the disease [11]. Enhanced MRI is better for characterizing the extent of the disease and the intracranial or intraorbitary complications [3, 9, 11]. Generally, antibiotics and mostly also surgical intervention are required, especially in case of complications [2, 5, 7, 8, 9, 11].

Differential Diagnosis List

Pott's puffy tumour arising from sinusitis

Sinusitis

Abscess

Fracture

(Orbital) Cellulitis

Haematoma

Osteomyelitis

Non-Hodgkin\'s lymphoma [12]

Lipoma

Final Diagnosis

Pott's puffy tumour arising from sinusitis

References

[1] Aínsa Laguna D, Pons Morales S, Muñoz Tormo-Figueres A, Vega Senra MI, Otero Reigada MC. (2014) Pott\'s puffy tumor: a rare complication of frontal sinusitis. An Pediatr (Barc) 80(5):317-20. doi: 10.1016 (PMID: 24103248)

[2] Ketenci I1, Unlü Y, Tucer B, Vural A. (2011) The Pott\'s puffy tumor: a dangerous sign for intracranial complications. Eur Arch Otorhinolaryngol 268(12):1755-63 (PMID: 21660452)

[3] Blumfield E, Misra M. (2011) Pott\'s puffy tumor, intracranial, and orbital complications as the initial presentation of sinusitis in healthy adolescents, a case series. Emerg Radiol 18(3):203-10 (PMID: 21380513)

[4] Tsai BY, Lin KL, Lin TY, Chiu CH, Lee WJ, Hsia SH, Wu CT, Wang HS (2010) Pott\'s puffy tumor in children. Childs Nerv Syst 26(1):53-60. (PMID: 19727764)

[5] Masterson L, Leong P. (2009) ). Pott\'s puffy tumour: a forgotten complication of frontal sinus disease. Oral Maxillofac SurgJ 13(2):115-7. (PMID: 19352731)

[6] Karaman E, Hacizade Y, Isildak H, Kaytaz A. (2008) Pott\'s puffy tumor. J Craniofac Surg 19(6):1694-7 (PMID: 19098585)

[7] Bannon PD, McCormack RF. (2011) ) Pott\'s puffy tumor and epidural abscess arising from pansinusitis. J Emerg Med 41(6):616-22 (PMID: 19022612)

[8] Parida PK, Surianarayanan G, Ganeshan S, Saxena SK. (2012) ). Pott\'s puffy tumor in pediatric age group: a retrospective study. Int J Pediatr Otorhinolaryngol 76(9):1274-7 (PMID: 22704674)

[9] Nicoli TK, Mäkitie A (2014) Frontal Sinusitis Causing Epidural Abscess and Puffy Tumor. N Engl J Med 370:e18 (PMID: 24620894)

[10] Acke F, Lemmerling M, Heylbroeck P, De Vos G, Verstraete K. (2011) Pott\'s puffy tumor: CT and MRI findings. JBR-BTR 94(6):343-5 (PMID: 22338391)

[11] Reid JR. (2004) Complications of pediatric paranasal sinusitis. Pediatr Radiol 34(12):933-42 (PMID: 15278322)

[12] Wong EH, Yang WY, Lowe D. (2013) Unilateral non-Hodgkin\'s lymphoma of the frontal sinus presenting as Pott\'s puffy tumour. Otolaryngol Pol 67(4):214-7 (PMID: 23911051)

Case information

URL:	https://www.eurorad.org/case/12557
DOI:	10.1594/EURORAD/CASE.12557
ISSN:	1563-4086

Figure 1

Sinusitis

Axial CT image showing obliteration of the maxillary sinus.

Axial CT image showing obliteration of the ethmoidal cells.

Axial CT image showing obliteration of the left frontal sinus.

Figure 2

Periosteal reaction

Axial CT images, bone window, showing the periosteal reaction of the wall of the maxillary sinus, indicating a chronic inflammatory disease.

Figure 3

Osteomyelitis of the left frontal bone

Axial CT images, bone window, showing the intact wall of the left frontal sinus at this level.

Axial CT images, bone window, showing the destruction/ osteolysis of the left frontal bone, comunicating with the frontal sinus.

Axial CT images, bone window, showing the osteolysis/destruction of the left frontal bone.

Figure 4

Osteomyelitis with subperiostal and extraaxial abscess

Axial CT images showing the obliteration of the frontal sinus as well as the subcutaneous swelling.

Axial CT images showing the obliteration of the frontal sinus and the left frontal extra-axial inhomogeneous lesion - abscess as well as the subcutaneous swelling.