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

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