Pott Puffy Tumor Appearing With a Frontocutaneous Fistula:

A Systematic Review of Intracranial Complications in Adults with Pott Puffy Tumor over Four Decades

The purpose of this study is to investigate the risk factors of intracranial complications in adult patients with Pott Puffy Tumor (PPT). A systematic review was conducted of clinical studies from January 1983 to December 2022 that reported on PPT adult patients. The full-text articles were reviewed for the patients’ ages, sex, cultured organisms, surgical procedures, clinical sequalae, and underlying diseases that may affect the onset of intracranial complications in PPT adult patients. A total of 106 studies were included. Medical data were reviewed for 125 patients (94 males, 31 females). The median age was 45 years. A total of 52% had comorbidities, mostly head trauma (24.5%), sinus/neurosurgical operations (22.4%), immunosuppression conditions (13.3%), diabetes mellitus (9.1%), cocaine use (7.1%), or dental infections (6.1%). A total of 28 cultures revealed Streptococcus (22.4%), 24 contained staphylococci (19.2%), and 22 cultures contained other pathogens (17.6%). An amount of 30.4% developed intracranial complications, with the most common being epidural abscesses or empyemas (55.3%), as well as subdural (15.7%) and extradural lesions (13.2%). Age, DM, and immunosuppression conditions are significantly associated with intracranial complications (p < 0.001, p = 0.018 and p = 0.022, respectively). Streptococcus infection is associated with intracranial complications (p = 0.001), although Staphylococcus and other microorganisms are not. Surgical intervention, mainly ESS, and broad-spectrum antibiotics remain the cornerstones of treatment.

The rare presentation of a frontal mucocele complicated by a Pott’s puffy tumor and an epidural-cutaneous fistula: illustrative case

BACKGROUND

Frontal mucoceles develop due to accumulation of mucoid secretions within the frontal sinuses. They can lead to serious consequences with further expansion and destruction of the surrounding bones or infection that might spread intracranially.

OBSERVATIONS

The authors present a case of a 37-year-old male with a frontal mucocele and the rare presentation of Pott’s puffy tumor and an epidural-cutaneous fistula, as well as a literature review of previously reported cases of epidural cutaneous fistula and sinocutaneous fistula, their predisposing factors, and their management.

LESSONS

A mucocele is a benign entity that can rarely present with potentially significant complications. Open surgery is required in patients who have frontal sinus posterior wall involvement, osteomyelitis, or intracranial involvement.

Pott's puffy tumor: A comprehensive review of the literature

PURPOSE

Pott's puffy tumor (PPT) is a rare clinical entity characterized by osteomyelitis of the frontal bone with subperiosteal abscess collection. The frequency of reported cases of PPT in the literature has increased in recent years. Previous reviews of PPT exist primarily in the form of small, retrospective case series and anecdotal case reports. Therefore, the aim of this study is to provide the literature's largest comprehensive, up-to-date review of the essential clinical findings, diagnostic modalities, microbiologic considerations, and treatment approaches utilized in the management of PPT, both in pediatric and adult populations.

MATERIALS AND METHODS

We searched MEDLINE, PubMed, and Embase databases for English-language studies published from January 1950 through January 30, 2022. The authors reviewed all cases of PPT, focusing specifically on those describing therapeutic management of PPT. A total of 321 patients were included, consisting of 318 patients (from 216 articles) and an additional 3 adult cases from our institution.

RESULTS

PPT most often results from untreated rhinosinusitis, as well as direct head trauma, substance use, and odontogenic disease. Infections are classically polymicrobial with an anaerobe-predominant microbiome. Both CT and MRI imaging modalities are commonly obtained for presurgical assessment of sinusitis and intracranial extension. The core of treatment is an early and aggressive approach to prevent long-term complications. A significant association exists between surgical management and clinical outcomes for patients with PPT. Recent literature suggests endoscopic sinus surgery is essential for successful disease resolution.

CONCLUSIONS

PPT is an important and relatively morbid disease process that is often underrecognized and misdiagnosed at presentation due to its variable clinical presentation. Management of PPT includes both antimicrobial therapy and surgical intervention. Determination of the optimal approach depends on patient clinical features including age, history of prior endoscopic sinus surgery, and presence of intracranial involvement on presentation. An individualized, targeted, and interdisciplinary approach to the treatment of PPT is critical for successful disease resolution.

Pott's puffy tumor caused by Actinomyces naeslundii

Pott’s puffy tumor is characterized by forehead swelling from subperiosteal abscess and frontal bone osteomyelitis. It is encountered mainly in children; rarely in adults. When it does occur in the latter population, the most common risk factors include head trauma, sinusitis, or cocaine abuse. Generally, the organisms thought to be involved include streptococci, staphylococci and oral anaerobic flora. We present a case of a 53 year old female who presented with forehead swelling of 3 month duration after a dental procedure, found to be secondary to Actinomyces naeslundii. Actinomyces is a very rare etiology of this disease and has been reported only twice earlier in the literature. We present an uncommon infectious disease along with summary of clinical characteristics of this entity in the adult population.

Sinocutaneous Fistula Formation After Forehead Recontouring Surgery for Transgender Patients

Forehead recontouring is a common part of facial feminization surgery. The procedure, which alters the shape and structure of the frontal bone, is regarded as safe and well tolerated by patients. The occurrence of delayed complications, however, is much less understood. The authors describe a patient involving the development of a sinocutaneous fistula as a delayed complication of forehead recontouring surgery. The clinical presentation and management of this patient are discussed. As facial feminization surgery expands as a cosmetic option for patients who desire more feminine facial features, practitioners should recognize the potential risk of sinonasal complications associated with forehead recontouring surgery.

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.

Anterior table remodeling after treatment for Pott's puffy tumor

We report a case of near-complete remodeling of the anterior table of the frontal sinus after treatment for an erosive Pott's Puffy Tumor. A 61-year-old male presented with progressive swelling of his left forehead. Examination showed a doughy left forehead mass, and a sinus CT showed a lateral left frontal sinus mucocele with complete anterior table erosion. Frontal trephination with marsupialization of the mucocele was performed, and at 8 month follow-up, the patient had no visible defect and only minimally palpable bony defect. The anterior table had remodeled with no additional intervention resulting in a cosmetic outcome imperceptible from the patient's baseline.