ORL 93 AW - French Oto-Rhino-Laryngology

CASE REPORT
Pott’s puffy tumour, a rare complication of
frontal sinusitis
Marta Monteiro, Rosa Castillo, Carla André, Mário Santos, Luís Antunes, João Marta Pimentel
Service d’ORL – Hôpital Garcia de Orta - Av. Torrado da Silva, 2801-951 - Almada - Portugal
ABSTRACT
Pott’s puffy tumour, corresponding to frontal osteomyelitis causing erosion of the anterior wall of the frontal sinus
and subperiosteal abscess, is a rare but serious complication of frontal sinusitis or trauma to the region. It can occur
even despite the use of antibiotics and requires surgical drainage of the abscess, excision of pathological tissues and
obliteration of the frontal sinus by various materials. It can rarely progress to life-threatening intracranial extension.
Practitioners must be extremely cautious in the presence of clinical signs suggestive of Pott’s puffy tumour.
Submitted for publication: October 2005
Accepted for publication: November 2007
Corresponding author: Marta Monteiro
Service d’ORL – Hôpital Garcia de Orta - Av.
Torrado da Silva, 2801-951 - Almada - Portugal
e-mail: marta_m3377@hotmail.com
(Fr ORL-2007;93:350-352)
(Presented in 2005 at the 112 th Congress of the French Society of ORL)
Fr ORL - 2007 ; 93 : 350

INTRODUCTION
Pott’s puffy tumour is characterized by frontal osteomyelitis
causing erosion of the anterior wall of the fro ntal
sinus and subperiosteal abscess [1,2], pre s e n t i n g
with fluctuating, painful swelling of the forehead [1].
It is a complication of frontal sinusitis, or, more rarely,
t rauma to this region [2,3]. The pat h ogens most freq
u e n t ly incri m i n ated are Stap hylococcus aure u s ,
Streptococci and anaerobic bacteria [1,3]. The use of
antibiotics has decreased the incidence of this complication
of sinusitis [4,5].
CASE REPORT
A 32-year-old, male Caucasian patient presented with
a one-month history of frontal headache and nasal obstruction.
Clinical examination revealed bilateral frontal
and periorbital oedema. This patient reported a history
of heroin use. Computed tomography of the face
revealed fe at u res of pansinusitis with a bone defe c t
measuring about 1 cm in diameter in the anterior wall
of the right frontal sinus, opacifi c ation of the right fro ntal
sinus and thickening of adjacent epicranial tissues.
Tre atment consisted of surge ry and antibiotics. A combined
endoscopic and open incision (bu t t e r fly incision),
was perfo rm e d, fo l l owed by surgical dra i n age of the
abscess with resection of necrotic fragments, and obliteration
of the right frontal sinus with medium viscosity
bone cement. A sample of the contents of the abscess
was collected for bacteri o l ogical culture. Initial
antibiotic therapy consisted of empirical tre atment with
intravenous gentamicin and clindamycin. As cultures
we re negat ive, this tre atment was continued for one
week, fo l l owed by oral cipro fl oxacin for six we e k s .
B ro a d - s p e c t rum antibiotics we re used immediat e ly
postoperatively and in the longer term due to the severity
of the infection.
The postoperative course was uneventful. Six months
later, no abnormality was detected on clinical examin
ation and computed tomograp hy showed opacifi c ation
of the right frontal sinus with no pat h o l ogical signs.
The patient was asymptomatic 14 months after surge ry.
DISCUSSION
Pott’s puffy tumour was described by Percivall Pott in
1760 in Injuries of the Head from External Vi o l e n c e
[3] as a complication of trauma. This disease was subsequently
observed as a complication of frontal sinusitis
[2]. It has become very rare since the age of anti-
351 - Fr ORL - 2007 ; 93
Pott’s puffy tumour
biotics, with very few cases reported in the recent literature
[2,4,5]. This disease is more frequent in children
[2] and young male adults [6].
The nasal sinus infection can be responsible for frontal
osteomyelitis by direct extension of infection to bone
or by thrombophlebitis of diploic veins. This extension
of frontal osteomyelitis can erode the anterior wall of
the frontal sinus and fo rm a subperiosteal abscess ge n erating
a fl u c t u ating and painful swelling of the fo rehead
[1].
The diagnosis of Pott’s puffy tumour must be considered
when clinical ex a m i n ation reveals a fl u c t u ating and
painful swelling of the forehead in a patient with frontal
sinusitis or a history of trauma to this region. The
diagnosis is confirmed by CT examination of the face
[1,5].
This case rep o rt presented the typical fe at u res of the
disease: young male adult with pansinusitis and a very
painful fluctuating swelling of the forehead.
Treatment consists of surgical drainage of the abscess,
excision of necrotic fragments and intravenous antibiotics
for 6 weeks, adapted to the pat h ogen [1,6].
S u rge ry via a combined ap p ro a ch (endoscopic and
open) gives good results [6]. As exposure of the entire
frontal sinus and resection of all pathological mucosa
is essential, obl i t e ration of the frontal sinus can be easily
performed [1]. Obliteration materials may be synthet
i c, such as hy d rox yap atite cement, or nat u ral: bone,
fat or cart i l age [7]. Hydrox yap atite cement is a safe and
e ffe c t ive obl i t e ration mat e rial for infected frontal sinu s
and for reconstruction of frontal sinus defects [8]. This
t e chnique is associated with minimal morbidity and can
achieve complete osseointegration [8,9]. Topical treatment
is also important with nasal vasoconstrictors and
mucolytics [6].
Pott’s puffy tumour can be complicated by potentially
fatal intracranial extension such as extradural or subdural
empyema, cerebral abscess and/or cerebral vein
thrombosis [10].
CONCLUSION
C o m p l i c ations of sinusitis have decreased as a re s u l t
of the use of antibiotics, but continue to occur sporadically.
Ear, nose and throat surgeons and primary care
physicians must therefore be aware of this possibility.
Pott’s puffy tumour, although very rare, can be comp
l i c ated by intra c ranial extension that can be fatal. Po t t ’s

Figure 1: Computed tomography of the face
s h owing pansinusitis, bone defect measuri n g
about 1 cm in diameter in the anterior wall
of the right frontal sinus, opacifi c ation of the
right frontal sinus and thickening of the
adjacent epicranial tissues.
Fi g u re 2: Surgical dra i n age of the ab s c e s s
with resection of necrotic fragments.
Figure 3: Postoperative computed tomography:
opacification of the right frontal sinus.
Pott’s puffy tumour
p u ffy tumour re q u i res early diagnosis and tre at m e n t
consisting of emergency surgery and appropriate antibiotics.
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