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LETTER TO EDITOR
Year : 2010  |  Volume : 58  |  Issue : 5  |  Page : 815-817

Recurrent Pott's puffy tumor, a rare clinical entity


Department of ENT, GSVM, Medical College, Kanpur, UP, India D-8, Shastri Nagar, Meerut, India

Date of Acceptance27-Jul-2010
Date of Web Publication28-Oct-2010

Correspondence Address:
Sumit Upadhyay
Department of ENT, GSVM, Medical College, Kanpur, UP, India D-8, Shastri Nagar, Meerut
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.72206

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How to cite this article:
Upadhyay S. Recurrent Pott's puffy tumor, a rare clinical entity. Neurol India 2010;58:815-7

How to cite this URL:
Upadhyay S. Recurrent Pott's puffy tumor, a rare clinical entity. Neurol India [serial online] 2010 [cited 2019 Sep 19];58:815-7. Available from: http://www.neurologyindia.com/text.asp?2010/58/5/815/72206


Sir,

Pott's puffy tumor, a feature of osteomyelitis of the frontal bone, is a rare entity in post-antibiotic era. It has been reported in older children and very rarely in adults.

A 29-year-old man met with a road traffic accident, causing open wound over forehead, 5 years back. He was operated by bicoronal flap approach, with obliteration of frontal sinus with fat. Five years after surgery, he had boggy forehead swelling, with intense pain. Local examination showed erythema and tense edema of the right upper lid, as well as forehead swelling measuring 8Χ6 cm [Figure 1]. There was thinning of skin, suggestive of pus under pressure with impending rupture of abscess. On palpation, warm, tender, fluctuating and doughy pitting edema [1] in the region of frontal sinus was found, with breach in continuity in anterior wall of frontal sinus. Rest of the general examination revealed no abnormality. Twenty-five milliliters of thick, yellow-colored pus was aspirated. Pus culture grew Staphylococcus aureus, sensitive to levofloxacin. He was relieved on medical therapy and refused surgical intervention. After symptom-free period of 2 months, there was recurrence of swelling of forehead. Contrast computerized tomography (CE-CT) [Figure 2] showed soft tissue swelling and edema around the superior aspect of the right orbit with slight proptosis. There was breach in the continuity in anterior wall of frontal sinus with foamy foreign body-like material (later identified as fat). Posterior bony wall of frontal sinus was intact and thickened, suggesting chronic osteomyelitis. Frontal recess was clear; no discharge was seen on nasal endoscopy. Evacuation of pus, debridement of necrotic tissue, granulation and resection of osteomyelitic bone was done by osteoplastic flap technique. Using a 4-mm, 30-degree endoscope, frontal recess and frontal ostia were widened; sialastic drain was put for drainage of sinus through the nose. Reconstruction/ obliteration was deferred due to underlying osteomyelitis.

Pott's puffy tumor was first described by Sir Percival Pott in 1760. [2] It is defined as "subperiosteal abscess presenting as a fluctuant mass over the forehead with underlying frontal bone osteomyelitis". It is seen predominantly in children, [3] as complication of frontal sinusitis, forehead trauma. [4] Other causes include intranasal methamphetamine, post-craniotomy and hair transplant. High index of suspicion based on the history and clinical examination is necessary to identify this rare but grave condition. When a patient presents with a fluctuant swelling of the forehead following sinusitis or trauma, imaging by CE-CT [5] or magnetic resonance imaging (MRI) should be done. Neurological complications should be ruled out. Treatment of Pott's puffy tumor requires multidisciplinary approach by neurosurgeons, otorhinolaryngologists and ophthalmologists, for prompt endoscopic/external drainage of sinus and removal of sequestrum, along with intensive antibiotic treatment.
Figure 1 :Swelling of the right upper eyelid and forehead, with erythema. On palpation, temperature raised, marked tenderness and fluctuation present, with breach in continuity of anterior wall of frontal sinus

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Figure 2 :CECT PNS showing breach in continuity of bone, with fluid-air level

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 » References Top

1.Percival Pott. Brief biography. Available from: http://www.whonamedit.com. [accessed in 2010].  Back to cited text no. 1
    
2.Pott P. Observations on the nature and consequences of those injuries to which the head is liable from external violence. In: Hawes L, Clarke W, Collins R, editors. London: Paternoster Row; 1768. p. 48.  Back to cited text no. 2
    
3.Adame N, Hedlund G, Byington CL. Sinogenic intracranial empyema in children. Pediatrics 2005;116:461-7.  Back to cited text no. 3
    
4.Martinez-Diaz GJ, Hsia R. Pott′s Puffy tumor after minor head trauma - A Case report. Am J Emerg Med 2008;26:739.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Durur-Subasi I, Kantarci M, Karakaya A, Orbak Z, Ogul H, Alp H. Pott′s puffy tumor: multidetector computed tomography findings. J Craniofac Surg 2008;19:1697-9.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  


    Figures

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