Pott's Puffy Tumor: A Rare Manifestation

Abstract

Pott's puffy tumor is a rare condition related to frontal sinus osteomyelitis and scalp abscess observed in children and young adult. Incidence of the condition in immune-competent individuals is rare. An adolescent febrile male presented with scalp swelling with nasal stuffiness and left periorbital swelling. Computed tomography (CT) brain showed frontal sinus abscess with a scalp abscess. Debridement and drainage of the abscesses were done in emergency. Repeat CT brain showed a new intracranial subdural collection. An immunocompetent individual with Pott's puffy tumor with subsequent development of subdural abscess in the postop period is a very unusual incidence.

Key Messages

1. An immunocompetent individual with Pott's puffy tumor is a very rare incidence.

2. Development of subdural abscess in the postop period that was not present in earlier scans is rare.

3. Early diagnosis and appropriate management can reduce the morbidity and mortality of the patient.

Keywords

Pott's puffy - tumor - osteomyelitis - frontal sinusitis

Background

Pott's puffy is a condition of osteomyelitis of the frontal bone and adjacent scalp abscess, first described by Sir Percival Pott.[1] Earlier thought to be associated with trauma, recurrent sinobacterial frontal sinusitis was later found to be the most common cause especially who have a hypoplastic sinus.[2] Complete evaluation in the form of contrast computed tomography (CT) (brain and the peripheral nervous system) is needed to rule out sinusitis bony involvement, and magnetic resonance imaging for soft tissue involvement and thrombosis of the veins.[3] The key management is with open or endoscopic drainage of the sinus by stripping off the mucosa and debridement of the bone osteomyelitis.[4] The remote sites for subdural empyema have been explained in the literature.[5] [6]

Case History

We present a case of a 12-year-old boy with a history of recurrent nasal stuffiness for 6 months with high-grade fever for 6 days with a 3 cm × 3 cm frontal scalp swelling and left periorbital swelling for 3 days. There was no neurological deficit. He underwent a noncontrast CT brain already from outside, which showed a frontal sinus abscess with an adjacent large visible scalp abscess ([Fig. 1]). An emergency drainage was performed in view of clinical deterioration in sepsis and was operated without delay. A bicoronal skin flap was taken. The scalp abscess was drained. The pus was sent for cytology and confirmed. The bone over the frontal sinus was unhealthy, which was debrided, and the sinus was opened. Unhealthy bone was removed, and the mucosa was scrapped and scalp closure was done. The immediate postoperative period was uneventful. However, on day 3 the patient developed severe headache with vomiting. Repeat scan showed a right frontoparietal subdural collection, which rarely occurs in response to migration of infection via subdural veins ([Fig. 2]). He was reexplored and decompressive craniotomy with subdural abscess drainage was done ([Fig. 3]). Pus culture was sterile. A follow-up CT scan after 3 weeks showed no residual subdural collection ([Fig. 4]). He was kept on intravenous antibiotics for 4 weeks and discharged on improvement.

Fig. 1 Computed tomography (CT) brain in the axial section showing frontal sinus with purulent collection and scalp collection.

Fig. 2 Computed tomography (CT) brain in postop (day 3) showing right frontoparietal subdural purulent collection.

Fig. 3 Intraoperative picture of the patient.

Fig. 4 Postop computed tomography (CT) brain, after the second surgery.

Conflict of Interest

None declared.

Acknowledgment

We acknowledge SOA University for the unconditional support.

• References

• 1 Apostolakos D, Tang I. Image diagnosis: Pott puffy tumor. Perm J 2016; 20 (03) 15-157
• 2 Joo MJ, Schapira KE. Pott's puffy tumor: a potentially deadly complication of sinusitis. Cureus 2019; 11 (12) e6351
• 3 Hasan I, Smith SF, Hammond-Kenny A. Potts puffy tumour: a rare but important diagnosis. J Surg Case Rep 2019; 2019 (04) rjz099
• 4 van der Poel NA, Hansen FS, Georgalas C, Fokkens WJ. Minimally invasive treatment of patients with Pott's puffy tumour with or without endocranial extension - a case series of six patients: our experience. Clin Otolaryngol 2016; 41 (05) 596-601
• 5 Lundy P, Kaufman C, Garcia D, Partington MD, Grabb PA. Intracranial subdural empyemas and epidural abscesses in children. J Neurosurg Pediatr 2019; 24 (01) 14-21
• 6 Yoon J, O'Bryan CM, Redmond M. Intracranial subdural empyema – a mini review. J Infectiol 2020; 3 (01) 1-5

Publication History

Article published online:
02 April 2025