Pott's puffy tumor in children

Pott's puffy tumor: as a very rare and unpredicted complication of ipsilateral pan sinusitis - case presentation and review of articles

Pott's puffy tumor is considered as a rare clinical entity. It is developed as a rare complication of frontal sinusitis. In addition, the trauma to the frontal area is another suggested cause. The Pott's puffy tumor is presented as a forehead swelling due to sub-periosteal collection. Although, the Pott's puffy tumor is a rare condition but at the same time, it can be serious because it may lead to life threatening complications namely, extradural abscess, subdural abscess, meningitis, encephalitis, and brain abscess. Thus, the Pott's puffy tumor is classified as a very significant surgical emergency.

Sinogenic Intracranial Suppuration in Children: Systematic Review and Meta-analysis

OBJECTIVE

To evaluate temporal trends in the management of sinogenic intracranial suppuration and its outcomes in children.

DATA SOURCES

A systematic search of databases was performed (Medline, Embase, Cochrane, ClinicalTrials.gov).

REVIEW METHODS

Studies in children (age <18 years) with sinogenic subdural empyema, extradural abscess, and intraparenchymal abscess were included. Data on treatment strategies were extracted. Primary outcome was death <90 days. Secondary outcomes were return to theater, neurologic disability at 6 months, and length of stay. Random effects meta-analysis and meta-regression were performed to investigate the effect of time and endoscopic sinus surgery (ESS) on these outcomes.

RESULTS

A total of 32 retrospective observational studies involving 533 patients recruited across a 45-year period (1975-2020) were included. The pooled estimates for 90-day mortality, permanent neurologic disability, and return to theater were 2.3% (95% CI, 1.1%-3.6%; I² = 0, P > .99), 21.3% (95% CI, 15.3%-27.3%; I² = 75.2%, P < .001), and 37.3% (95% CI, 29.5%-45%; I² = 71.2%, P < .001), respectively, with no significant differences found across the study period. The pooled estimate for ESS was 58.4% (95% CI, 44.2%-72.6%; I² = 97.1%, P < .001) with a significantly increasing trend in its use in the more recent years. ESS was not associated with improved mortality, reduced need for revision surgery, or neurologic disability.

CONCLUSION

The outcomes of sinogenic intracranial complications have not changed over the last 45 years, and ESS was not associated with improved patient outcomes. Further high-quality studies are required to determine the most appropriate treatment modalities to improve the burden of morbidity associated with sinogenic intracranial suppuration in children.

A Case of Pott's Puffy Tumor Associated With Barosinusitis From Scuba Diving

ABSTRACT

Barosinusitis, or sinus barotrauma, is a well-described condition associated with changes in barometric pressure during flight and diving that can result in sinonasal mucosal injury. In this case report, we present an adolescent who experienced barosinusitis during scuba diving and subsequently developed Pott's puffy tumor (PPT), characterized by frontal sinusitis, frontal bone osteomyelitis, and overlying subperiosteal abscess. This unique case of PPT following scuba diving provides the opportunity to review the pathophysiology of both barotrauma-induced sinus disease and PPT, a rare and unreported serious complication of barosinusitis. Furthermore, we discuss how scuba diving and associated barosinusitis can be considered a risk factor in the development of PPT.

Bicoronal Incision and Frontal-Basal Approach for Removal of Sinonasal Fibrous Dysplasia Complicated by Orbital Subperiosteal Abscess

BACKGROUND

Fibrous dysplasia (FD) is a benign, slowly progressive disease resulting from the replacement of normal bone by fibro-osseous tissue. The incidence of craniofacial involvement of FD is as high as 23%. Sinonasal involvement of FD may lead to obstruction of the natural sinus ostium, resulting in acute sinusitis. We present a rare case of sinonasal FD complicated by subperiosteal abscess that was removed by bicoronal incision and frontal-basal approach in the second surgery.

CASE DESCRIPTION

A 16-year-old male patient presented with painful swelling on his left eye that had persisted for 2 days. Transnasal endoscopic drainage of the left orbital subperiosteal abscess was performed and progressive improvement of the swelling of the left eye was noted. After the acute phase, transcranial removal of the sinonasal bony lesion and mesh reconstruction of the left orbital wall were performed. There has been no progression of FD to date, with 24 months of follow-up.

CONCLUSIONS

After the acute phase, radical excision with reconstruction or debulking surgery after skeletal maturation may prevent recurrence. Although malignant transformation is rare, long-term follow-up is necessary for FD.

Treatment of pediatric extra-axial sinogenic infection: case series and literature review

PURPOSE

Analyze the clinical presentation, microbiology, outcomes, and medical and surgical treatment strategies of intracranial extension of sinogenic infection in pediatric patients.

METHODS

A retrospective, single-center study of patients < 18 years of age, presenting with intracranial extension of bacterial sinogenic infections requiring surgical intervention over a 5-year period, was conducted. Electronic medical records were reviewed for age, sex, primary symptoms, duration of symptoms, presence of sinusitis at initial presentation, microorganisms isolated, mode of surgery, timing of surgery, length of stay, and neurologic sequelae.

RESULTS

Seventeen patients were identified; mean age was 10 years with 82.3% male predominance. Average duration of illness prior to presentation was 9.8 days, with 64.7% of patients displaying disease progression while on oral antibiotics prior to presentation. Sinusitis and intracranial extension were present in all patients upon admission. Simultaneous endoscopic endonasal drainage and craniotomy were performed on 70.5% of the patients, with the remaining 29.5% undergoing endonasal drainage only. Of the patients who underwent simultaneous endoscopic endonasal drainage and craniotomy, 17.6% required repeat craniotomy and 5.8% required repeat sinus surgery. The most commonly isolated organisms were S. intermedius (52.9%), S. anginosus (23.5%), and S. pyogenes (17.6%). All patients were treated postoperatively antibiotic on average 4-6 weeks. Frequently occurring long-lasting complications included seizures (29.4%) and focal motor deficits (17.6%); learning disability, anxiety disorders, impaired cognition, and sensory deficits occurred less frequently.

CONCLUSION

In the case of intracranial extension of bacterial sinogenic infection, early identification and surgical treatment are crucial to avoid neurological sequelae.

Potts puffy tumour: a rare but important diagnosis

Potts puffy tumour (PPT) is a subperiosteal abscess arising from frontal bone osteomyelitis. We present a case of a 75-year-old lady with headache and a forehead swelling who was initially treated for sinusitis and giant cell arteritis in a primary care setting, but failed to improve. Following clinical deterioration and further investigation, CT appearances were consistent with a diagnosis of PPT and an extra-axial collection. Needle decompression, frontal trephine and endoscopic frontal sinusotomy were performed and intraoperative swabs cultured Streptococcus constellatus PPT is an unusual clinical entity that benefits from prompt antibiotic and surgical management, and therefore early recognition is paramount. We highlight that PPT should be a differential diagnosis in all patients presenting with forehead or frontal swelling. Use of radiological imaging (CT/MRI) is necessary to not only confirm a diagnosis of PPT but to identify further intracranial complications, which can be life-threatening.

Pott's puffy tumor in children: A review of the literature

OBJECTIVES

Pott's puffy tumor (PTT) is a frontal subperiosteal abscess associated with underlying frontal osteomyelitis. The purpose of the present study was to assess the rate of intracranial involvement in pediatric and adolescent patients with PPT and to discuss the diagnostic workup and the therapeutic features of this pathology.

METHODS

We searched Web of Science, PubMed and MEDLINE from 1998 to 2018. The search focused on papers concerning the diagnostic procedure and therapeutic management of PTT. Statistical techniques were not used.

RESULTS

We included 53 articles that described 92 pediatric and adolescent patients with PPT. The overall rate of intracranial complications was found to be 72%. Most authors used computed tomography for the diagnosis of PTT and its complications, either alone or in combination with magnetic resonance imaging. In 50% of cases, an endoscopic endonasal approach is used for the management of the underlying acute or chronic sinusitis.

CONCLUSIONS

On the basis of the available literature, it seems that the incidence rate of intracranial involvement in patients with PPT is quite high. Early diagnosis using the appropriate imaging raise the possibility of good recovery. Concerning the therapy of PTT, endoscopic sinus surgery could be considered as a valuable technique. The vast majority of patients treated appropriately recover without long-term neurologic complications and sequelae.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:225-231, 2020.

Pott puffy tumor

Pott puffy tumor is osteomyelitis of the frontal bone with associated subperiosteal abscess causing swelling and edema over the forehead and scalp. It is a complication of frontal sinusitis or trauma. We present the case of an 8-year-old girl with frontal swelling. Imaging evaluation showed frontal osteomyelitis as a complication of frontal sinusitis with associated epidural and subperiosteal abscess. The patient was treated surgically and recovered well. This case highlights the need for high clinical suspicion and early diagnosis and management to prevent life-threatening complications. Unfortunately, in our case the patient had to undergo surgery for this complication, which could have been prevented by earlier diagnosis.

Pseudotumor inflamatorio de Pott: una complicación olvidada y peligrosa de la sinusitis

El pseudotumor inflamatorio de Pott es una de las posibles complicaciones de la sinusitis. En la literatura existen pocos casos reportados de esta entidad, pero el presente artículo expone cuatro casos con el propósito de concientizar al grupo médico sobre la existencia de esta enfermedad y cómo su manejo temprano puede prevenir complicaciones severas.

Pott's puffy tumor due to Aspergillus fumigatus: A case report and review

Pott's puffy tumor (PPT) is a very rare, nearly forgotten condition. We describe a 9-year-old girl with PPT due to trauma and surgical cultures that revealed Aspergillus fumigatus.

Neurosurgical implications of Pott's puffy tumor in children and adolescents

INTRODUCTION

Pott's puffy tumor (PPT) is rare and usually seen as a complication of frontal sinusitis resulting in subperiosteal abscess of the frontal bone with underlying osteomyelitis. PPT is potentially severe and can lead to life-threatening intracranial complications.

PATIENTS AND METHODS

The authors present a series of six pediatric patients diagnosed with PPT and intracranial complications between 1999 and 2012. There were five boys and one girl, and the mean age at diagnosis was 11.8 years. All patients presented with frontal swelling, headache, and fever. Two patients had lowered level of consciousness and severe hemodynamic instability.

RESULTS

All patients had epidural abscess, and one also presented subdural empyema. Five patients underwent drainage of all associated abscesses, bone resection, and sinusitis treatment. One was treated conservatively with broad-spectrum antibiotics, and no surgical intervention was required. All patients fully recovered their neurologic status, without further complications.

Sinus imaging for diagnosis of chronic rhinosinusitis in children

Chronic rhinosinusitis (CRS) is a relatively common disease in children but is often overlooked because at times the clinical symptoms are subtle and nonspecific. This makes imaging very important in the diagnosis. Among the different techniques, plain radiography has limited utility,whereas CT scan and MRI have a major role in evaluating the modifications caused by the disease. In particular, a CT scan provides higher resolution of bone and soft tissue and removes the overlapping structures that are present in conventional radiography. CT is recommended in isolated sphenoid sinusitis, is essential in diagnosing fungal sinusitis, and is the technique of choice when orbital complications are suspected. MRI allows investigation of not only the morphology of structures, but their intrinsic biophysical and biochemical properties, such as water content, cellular density, lipid or blood product deposits, and fibrosis. MRI allows better soft tissue differentiation and high spatial resolution images depicting fine details. When indicated, MRI with contrast gadolinium-based agents may better characterize the local disease extension or its diffusion beyond paranasal and nasal cavities and has excellent contrast resolution. A combination of CT and MRI is useful in cases of diagnostic difficulties,especially when complications are involved.

Orbital Involvement in Pott's Puffy Tumor: A Systematic Review of Published Cases

Background

Pott's puffy tumor (PPT) is a frontal subperiosteal abscess associated with underlying frontal bone osteomyelitis. It represents a well-known source of sinogenic intracranial infection, but the orbital complications related to this entity are rarely reported. The goal of this study was to characterize the orbital involvement in PPT.

Methods

We performed a systematic review through a Medline search (1950–2010). The authors reviewed all cases of PPT, selecting those explicitly describing orbital complications associated with PPT.

Results

We screened 139 articles, of which 93 reported cases of PPT. Of these, 35 articles described a total of 42 cases presenting simultaneous orbital complications. Eyelid and/or periorbital edema was the most common finding in patients with orbital involvement, and preseptal cellulitis is by far the most prevalent orbital complication in PPT. Postseptal involvement (orbital cellulitis, subperiosteal abscess of the orbit, and orbital abscess) is much rarer. Although treatment of the classic PPT is surgical, only a minority of patients with orbital infection required orbital drainage. Most reported patients made a full recovery, without permanent sequelae.

Conclusion

Orbital infections are possible in patients with PPT. In contrast to surgical treatment of the frontal subperiosteal abscess, the orbital complications can be treated conservatively most of the time. Early diagnosis and aggressive therapy of the underling PPT are essential to avoid severe local or systemic complications.

Intracranial suppuration complicating sinusitis among children: an epidemiological and clinical study

OBJECT

Intracranial abscess is a very infrequent complication of sinusitis among children. Case series, mostly small and focusing on surgical treatment, have appeared in the literature, but there has been no study on the epidemiology of this condition, nor has there been any large-scale study on the intensity of therapy or outcomes.

METHODS

Data were drawn from the Kids' Inpatient Databases for 1997, 2000, 2003, and 2006 and the National Inpatient Sample for 2001. Cases were defined by the conjunction between the diagnostic codes for intracranial abscess and those for acute or chronic sinusitis or mastoiditis.

RESULTS

Eight hundred forty-seven hospital admissions were captured. Over the 10 years of the study, admission rates ranged between 2.74 and 4.38 per million children per year. Boys were affected much more commonly than girls. Black children were affected out of proportion to their presence in the population. The overall incidence seemed to peak in early adolescence. Sinogenic cases had a marked seasonal pattern peaking in winter, but no seasonal variation was seen for otogenic cases. Asthma comorbidity was more prevalent among sinogenic cases. The mortality rate was 2%, and death occurred only among sinogenic cases. Moreover, sinogenic cases tended to require more intensive therapy, as measured by the number of procedures, and there was a trend toward less favorable discharge dispositions. Older patients and black patients were less likely to be discharged directly to home. At least a quarter of the cases were managed without neurosurgical intervention. White patients were treated without neurosurgery more often than others.

CONCLUSIONS

Analysis of administrative data sets has yielded a descriptive picture of intracranial abscess complicating sinusitis among children, but the very low incidence of this condition impedes prospective clinical research directed at practical management issues.