SAEM Clinical Images Series: Pediatric Forehead Swelling

puffy

A 12-year-old male with a history of autism spectrum disorder and chronic sinusitis presented for forehead swelling. His mother reported that she noticed progressive forehead swelling for about one month. She had followed up with the patient’s pediatrician and ENT and was given oral cephalexin and fluticasone nasal spray which did not make any changes in his symptoms. The patient denied any fevers or headaches.

Vitals: Temp 97.4°F; BP 100/58; HR 90; RR 18; SpO2 98%.

General: Patient is comfortable appearing, in no acute distress.

ENT: 3×3 cm area of fluctuance centrally located over the forehead with no drainage or surrounding erythema that is minimally tender to palpation. No nasal drainage.

Neuro: Intact with no deficits.

WBC: 14.35

ESR: 23 mm/h

CRP: 0.74 mg/dL

CT demonstrates osteomyelitis of the frontal bone with osseous destruction with a 5 cm bifrontal complex loculated anterior epidural abscess as well as a 3 cm midline frontal subgaleal extracranial scalp abscess.

Findings are consistent with Pott’s Puffy Tumor.

Take-Home Points

  • Pott’s puffy tumor is a rare, life-threatening complication of frontal sinusitis characterized by osteomyelitis of the frontal bone with associated subperiosteal abscess causing swelling and edema over the forehead and scalp. It can be found in all age groups but is most common in adolescents.
  • MRI brain with and without contrast is the preferred imaging modality due to increased sensitivity to detect early intracranial and osseous abnormalities.
  • Treatment is typically surgical intervention with at least 6 weeks of intravenous antibiotics. The infection is typically polymicrobial warranting gram-positive, gram-negative, and anaerobic antibiotic coverage.

  • Sharma P, Sharma S, Gupta N, Kochar P, Kumar Y. Pott puffy tumor. Proc (Bayl Univ Med Cent). 2017 Apr;30(2):179-181. doi: 10.1080/08998280.2017.11929575. PMID: 28405074; PMCID: PMC5349820.
  • Masterson L, Leong P. Pott’s puffy tumour: a forgotten complication of frontal sinus disease. Oral Maxillofac Surg. 2009 Jun;13(2):115-7. doi: 10.1007/s10006-009-0155-7. PMID: 19352731.

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