SAEM Clinical Images Series: Facial Swelling

A 5-year-old male with a history of recent frontal sinusitis associated with preseptal cellulitis requiring surgery presented with facial swelling. Swelling developed in the 24 hours prior to presentation without facial pain, nausea, or emesis. Denied facial trauma as well as any neurologic deficits, loss of consciousness, headaches, or fever/chills. At the time of his prior surgery, he presented with swelling localized to the left eye along with worsening pain, nausea, and emesis. After surgery, he was discharged in stable condition on antibiotics for 10 days. He has been in his usual state of health since that time.

Additional Images

Physical Exam

Vitals: BP 93/59 (Sitting); HR 84; Temp 37.3 °C (99.1 °F) (Oral); Resp 12; Wt 20.6 kg (45 lb 6.6 oz)

General: Active, alert, normal development, and in no acute distress

HEENT: Swelling over the forehead and nasal bridge. Tenderness to palpation over the forehead. No erythema or overlying skin changes.

Nose: Normal appearance. No congestion or rhinorrhea.

Mouth/Throat: Mucous membranes are moist. Oropharynx is clear.

Laboratory Data

White blood cell (WBC) count: 8.9 x 10^3/uL

Hemoglobin: 11.5 g/dL

Platelets: 365 x 10^3/uL

ANC: 4.490 x 10^3/uL

ESR: 15 mm

CRP: <0.5 mg

Case Question: What is the best imaging modality in the emergency department to further evaluate this lesion?

In the initial management of this patient, CT imaging of the head with contrast should be used to characterize the lesion and evaluate for intracranial involvement. In our patient, the CT scan showed frontal bone osteomyelitis with possible extension into the subdural space. He was admitted on broad-spectrum antibiotics and surgical washout was performed the following day.

Case Question: What are the possible complications of this condition?

Pott’s Puffy Tumor is a rare but serious complication of sinusitis with potential intracranial involvement. Complications include orbital cellulitis, intracranial abscess, meningitis, and cavernous sinus thrombosis.

Case Discussion

Take-Home Points

Pott’s Puffy Tumor is a rare potential complication of sinusitis. Early diagnosis and treatment are essential to reduce morbidity.
CT of the head with contrast is the initial imaging that should be obtained in the emergency department.

References

Blumfield E1, Misra M. Pott’s puffy tumor, intracranial, and orbital complications as the initial presentation of sinusitis in healthy adolescents, a case series. Emerg Radiol. 2011 Jun;18(3):203-10. PMID: 21380513.
Palabiyik FB1, Yazici Z, Cetin B, Celebi S, Hacimustafaoglu M. Pott Puffy Tumor in Children: A Rare Emergency Clinical Entity. J Craniofac Surg. 2016 May;27(3):e313-6. PMID: 27100642.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2021 SAEM Annual Meeting | Copyrighted by SAEM 2021 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.