Pott's puffy tumor, first described by Sir

Percivall Pott Percivall Pott (6 January 1714, in London – 22 December 1788) was an English surgeon, one of the founders of orthopaedics, and the first scientist to demonstrate that cancer may be caused by an environmental carcinogen, namely chimney sweeps ...

in 1760, is a rare clinical entity characterized by subperiosteal abscess associated with

osteomyelitis Osteomyelitis (OM) is the infectious inflammation of bone marrow. Symptoms may include pain in a specific bone with overlying redness, fever, and weakness. The feet, spine, and hips are the most commonly involved bones in adults. The cause is ...

. It is characterized by an osteomyelitis of the

frontal bone In the human skull, the frontal bone or sincipital bone is an unpaired bone which consists of two portions.'' Gray's Anatomy'' (1918) These are the vertically oriented squamous part, and the horizontally oriented orbital part, making up the bo ...

, either direct or through haematogenic spread. This results in a swelling on the forehead, hence the name. The infection can also spread inwards, leading to an intracranial

abscess An abscess is a collection of pus that has built up within the tissue of the body, usually caused by bacterial infection. Signs and symptoms of abscesses include redness, pain, warmth, and swelling. The swelling may feel fluid-filled when pre ...

. Pott's puffy tumor can be associated with cortical vein thrombosis,

epidural abscess An epidural abscess refers to a collection of pus and infectious material located in the epidural space superficial to the dura mater which surrounds the central nervous system. Due to its location adjacent to brain or spinal cord, epidural absce ...

subdural empyema Subdural empyema is a form of empyema – a collection of pus, in the subdural space. Bacterial or occasionally fungal infection of the skull bones or air sinuses can spread to the subdural space, producing a subdural empyema. The underlying arac ...

, and

brain abscess The brain is an organ that serves as the center of the nervous system in all vertebrate and most invertebrate animals. It consists of nervous tissue and is typically located in the head ( cephalization), usually near organs for special sense ...

. The cause of vein thrombosis is explained by venous drainage of the frontal sinus, which occurs through diploic veins, which communicate with the dural venous plexus; septic thrombi can potentially evolve from foci within the frontal sinus and propagate through this venous system. This type of chronic osteomyelitis of the frontal bone is confused with acute sub-periosteal abscess of the frontal bone, which presents as a discrete collection over the frontal sinus. Although it can affect all ages, it is mostly found among teenagers and

adolescent Adolescence () is a transitional stage of human physical and psychological development that generally occurs during the period from puberty to adulthood (typically corresponding to the age of majority). Adolescence is usually associated w ...

s. It is usually seen as a complication of frontal

sinusitis Sinusitis, also known as rhinosinusitis, is an inflammation of the mucous membranes that line the sinuses resulting in symptoms that may include production of thick nasal mucus, nasal congestion, facial congestion, facial pain, facial pressure ...

or trauma. Medical imaging can be of use in the diagnosis and evaluation of the underlying cause and extent of the condition. Ultrasound is able to identify frontal bone osteomyelitis, while computed tomography (CT) can evaluate bony erosion, and along with magnetic resonance imaging (MRI), can better appreciate the underlying cause and extent of possible intra-cranial extension/involvement.

Cause

* Frontal sinusitis, acute or chronic. * Frontal trauma, usually blunt. * Some cases have been seen in a context of intranasal substance abuse (cocaine, methamphetamine). * Post-surgical: after frontal sinus reconstruction

Diagnosis

Diagnosis is suspected clinically and is confirmed using cross sectional imaging of the sinuses and brain. The patient typically presents with a headache overlying the frontal sinuses and an associated forehead swelling. This is often preceded by a history of chronic rhinosinusitis. Plain X Rays can be used to demonstrate the location of this swelling, but the gold standard for diagnosis is a cross sectional CT scan of the sinuses and brain, aided by contrast to delineate the abscess itself. File:Potts puffy tumor detail.jpg, Picture demonstrating associated forehead swelling in patient with Pott’s puffy tumor.

Treatment

The patient requires admission for intravenous anti-microbial treatment. Definitively, the abscess is drained via a combination of open and/or endoscopic approaches by an otolaryngologist, with the exact approach dependent on surgical skill set. At the very least, the abscess is trephined externally as an emergency. Any associated frontal sinus table fracture can be managed electively. Intracranial extension requires referral to the neurosurgery.

References

External links

* {{cite journal , pmid = 19098585 , doi=10.1097/SCS.0b013e31818b432e , volume=19 , issue=6 , title=Pott's puffy tumor , year=2008 , journal=J Craniofac Surg , pages=1694–7 , vauthors=Karaman E, Hacizade Y, Isildak H, Kaytaz A Skeletal disorders