extensive subgaleal abscess and epidural empyema in

Pott’s Puffy TumorA) B)Fig. 2. A) Pretreatment axial computed tomogram showing left maxillary opacification. B) Pretreatment coronal computedtomogram showing left ethmoid opacification.A) B)Fig. 3. A) Coronal computed tomogram showing air-fluid level in the left frontal sinus and extensive subgaleal abscess inthe bilateral parietal regions. Note: this section was taken in the supine position, showing fluid above air. B) Axial computedtomogram showing subgaleal abscess and epidural empyema.with prompt light reflex, unimpaired visual acuityand unlimited extraocular muscle movement. Nasalexamination revealed purulent discharge in the leftmiddle meatus. Laboratory investigations showedleukocytosis with a left shift; C-reactive protein was20.4 mg/dL (normal range, 0 to 5 mg/dL).Computed tomography (CT) demonstrated leftpansinusitis (Fig. 2A and 2B), extensive subgalealabscess in the bilateral frontoparietal regions andepidural empyema of the frontal lobe (Fig. 3A and3B). Bony destruction of the frontal sinus was noted,indicating osteomyelitis of the frontal bone (Fig. 4).A preoperative diagnosis of acute sinusitis complicatedby subgaleal abscess and epidural empyema was made,and the patient was taken to surgery.An eyebrow incision was performed in the gullwing fashion. As the scalp was incised, a significantamount of pus gushed from the incision. The scalphad been spontaneously dissected subgaleally byabscess formation. The outer table of the left frontalsinus was centrally eroded with a bony defect, activelydischarging pus. The defect was widened and bone withabnormal appearance was removed using an air drill.Mucoperiostectomy was performed. A bony defect ofthe inner table was found and a burr hole was drilled todrain the purulent, epidural accumulation. The inferiorwall was removed with preservation of the supraorbitalridge. Endoscopic sinus surgery was then conductedfor intranasal ethmoidectomy, particularly focusingon unroofing the frontal recess. Middle meatal antrostomywas also performed for the concomitant maxillarysinusitis. The scalp wound was vigorously irrigated andclosed in layers. Catheters were placed subgaleally fordrainage and removed 9 days after surgery.Intraoperative cultures grew viridans streptococci,coagulase-negative staphylococci and Peptostreptococcusmicros. The patient received 3 weeks of treatment withintravenous antibiotics (penicillin 3 MU 4-hourly,J Formos Med Assoc 2003 • Vol 102 • No 5 339

Pott’s Puffy Tumorcomplications. 7,8 Plain films may not demonstratemucosal thickening, bone erosion, or soft tissue changesseen with abscesses.Aggressive surgical drainage and debridement ofthe osteomyelitic bone remain the mainstay of therapy.Pott’s puffy tumor is best treated by trephinationthrough the medial aspect of the floor of the frontalsinus to decompress the infected sinus. Material may,thus, be obtained for culture and sensitivity tests. 6Recent advances in endoscopic sinus surgery haveprovided alternative access to the frontal recess todecompress the frontal sinus. Accurate assessment andthorough drainage of the abscess and removal ofosteomyelitic bone up to the margins of normal boneis essential to treat an extensive subgaleal abscessand spreading osteomyelitis. Close cooperation withthe neurosurgeon is necessary to deal with intracranialcomplications. Since patients who present withcomplications of acute frontal sinusitis frequently havemultisinus disease, drainage of the other diseased sinusmay prevent future episodes of sinusitis.The cultures from frontal sinusitis with complicationsfrequently reveal polymicrobial involvement.Streptococci, staphylococci and anaerobic bacteria arethe predominant pathogens. 9,10 Patients should bestarted on broad-spectrum intravenous antibioticsbefore availability of surgical culture results. A frequentlychosen combination is: 1) a third-generationcephalosporin; 2) metronidazole; and 3) a penicillinor vancomycin. Although penicillin is active againstmost anaerobes, most strains of Bacteroides fragilis areresistant. It has been suggested, therefore, that unlessanaerobes can be excluded, all paranasal sinusinfections failing to respond promptly or developingcomplications should be treated with metronidazolein addition to the normal therapeutic regimen. 11,12Thus, we chose combination therapy with penicillin,ceftriaxone, and metronidazole to treat this patient.Microbiological identification of the pathogens isimportant for administration of the most appropriateantimicrobial therapy. The duration of antimicrobialtherapy should be about 6 to 8 weeks. 1,11Extensive subgaleal abscess and epidural empyemaare rare complications of sinusitis in this postantibioticera. Nonetheless, the clinical course is fulminating andpotentially life-threatening. There must be a highindex of suspicion for prompt identification of sinusitiscomplications and prompt management in order toavoid further progression and debilitating sequelae.References1. Babu RP, Todor R, Kasoff SS: Pott’s puff tumor: the forgotten entity.Case report. J Neurosurg 1996;84:110-2.2. Thomas JN, Nel JR: Acute spreading osteomyelitis of the skullcomplicating frontal sinusitis. J Laryngol Otol 1977;91:55-62.3. Montgomery WW, Cheney ML, Jacobs EE: Osteomyelitis of thefrontal bone. Ann Otol Rhinol Laryngol 1989;98:848-53.4. Morgan PR, Morrison WV: Complications of frontal and ethmoidsinusitis. Laryngoscope 1980;90:661-6.5. Fairbanks DNF, Milmoe GJ: The diagnosis and management ofsinusitis in children. Complications and sequelae: an otolaryngologist’sperspective. Pediatr Infect 1985;4(Suppl):S75-8.6. Altman KW, Austin MB, Tom LWC, et al: Complications of frontalsinusitis in adolescents: case presentations and treatmentoptions. Int J Pediatr Otorhinolaryngol 1997;41:9-20.7. Singh B, Van Dellen J, Ramjettan S, et al: Sinogenic intracranialcomplications. J Laryngol Otol 1995;109:945-50.8. Wells RG, Sty JR, Landers D: Radiological evaluation of Pott puffytumor. JAMA 1986;255:1331-3.9. Verbon A, Husni RN, Gordon SM, et al: Pott’s puffy tumor dueto Haemophilus influenzae: case report and review. Clin InfectDis 1996;23:1305-7.10. Feder HM Jr, Cates KL, Cementina AM: Pott puffy tumor: aserious occult infection. Pediatrics 1987;79:625-9.11. Giannoni CM, Stewart MG, Alford EL: Intracranial complicationsof sinusitis. Laryngoscope 1997;107:863-7.12. Daya S, To SS: A ‘silent’ intracranial complication of frontalsinusitis. J Laryngol Otol 1990;104:645-7.J Formos Med Assoc 2003 • Vol 102 • No 5 341