American Journal of Emergency Medicine (2008) 26, 739.e1–739.e3
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Case Report Pott's Puffy tumor after minor head trauma Abstract Posttraumatic osteomyelitis may occur as a direct result of bony injury after trauma or arise as a nosocomial infection after the treatment of trauma [1]. Most cases arise after an open fracture, but bony infection can also arise from spread of infection from contiguous soft tissues or by puncture wounds. Motor vehicle accidents, sport injuries, and the use of orthopedic hardware to manage trauma have contributed to the apparent increase in prevalence of posttraumatic osteomyelitis [2]. We report on a case of Pott's Puffy tumor in a previously healthy woman who had an episode of minor forehead trauma 1 month before presentation to the emergency department (ED), complaining of persistent headache and swelling of her forehead. Results of computed tomography (CT) revealed features characteristic of this condition. After postobliteration of the left frontal sinus via a bicoronal approach with an iliac crest bone graft and some dental extractions and 2 weeks of antibiotic therapy, the patient achieved a complete recovery. A 54-year-old obese African American woman presented to the ED with a complaint of a growing mass on her forehead for the past month. One month before presentation, the patient had hit her head on a car door and developed a “bump” over the area, which had waxed and waned in size more than 3 weeks. This was accompanied by localized forehead pain and a few episodes of mild headaches, as well as several falls due to leg weakness. She denied any fevers, chills, nausea/vomiting, visual changes, or other systemic symptoms. Her main reason for coming to the ED now was “to figure out why my bruise has not gone down.” Her medical history was significant for obesity, gastroesophageal reflux disease, alcohol, and cocaine abuse, hypertension, arthritis, hepatitis C, and seizures secondary to cocaine use. Her surgical history was significant for the hysterectomy in 2000 and an open reduction internal fixation of the left femur and hip secondary to a motor vehicle accident in 1998. She was a married woman but separated and living in a shelter, and her social history was significant for cocaine, heroin, and tobacco use. 0735-6757/$ – see front matter © 2008 Elsevier Inc. All rights reserved.
Initial vital signs included a blood pressure of 170/86 mm Hg, pulse rate of 82 beats per minute, respiratory rate of 18 breaths per minute, temperature of 36°C, 98% oxygen saturation, and Glasgow Coma Scale of 15. On examination, the patient had a 4 × 4-cm fluctuant swelling over the glabella, and it was depressible in the forehead area. Her extraocular movements were intact, and her pupils were equally round and reactive to light and accommodation. Cranial nerves II through XII were grossly intact. Musculoskeletal examination revealed 3/5 left leg strength, with all other extremities 5/5, but she was able to ambulate without assistance. She had a negative Romberg sign and no dysdiadokinesia. She was alert and oriented, pleasant and talkative. The rest of the result of the physical examination was unremarkable. The patient's laboratory results were unremarkable, including a normal leukocyte count of 7.3 × 109/L. Although the patient looked remarkably well, the decision was made to
Fig. 1 Computed tomographic image coronal view with arrow pointing to the tumor.
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Fig. 2 Sagittal CT scan view with an arrow pointing to the 4 × 4 mass in the frontal aspect of the head.
obtain a CT scan of the head, sinuses, and orbits, which showed complete loss of the left frontal anterior table and a collection in the frontal sinus and in the overlying skin (Figs. 1 and 2). The otolaryngology service was consulted, and because the patient looked well, the otolaryngologist did not think osteomyelitis was likely and decided not to admit her but scheduled her for clinic to confirm the diagnosis. An irrigation and debridement procedure was done in clinic, and a large amount of separation was seen in her left frontal sinus. At this point, a possible diagnosis of Pott's Puffy tumor was considered. The patient was admitted to the hospital and placed on antibiotics and pain medication, and a neurosurgery consultation was obtained. The otolaryngology service then performed an evisceration of the left frontal sinus and reconstruction with a right iliac crest bone graft. This procedure was done by a coronal approach, and obtained copious amount of pus in the left frontal sinus was seen with erosion of the left frontal bone. During the postoperative course, the forehead contour continued to improve with decreased swelling and decreased associated edema. The microbiology broth isolated coagulase-negative Staphylococcus and β-hemolytic Streptococcus. Importantly, neurologically, her cranial nerve VII, the right hypoileogastric nerve, T12, and the right cutaneous femoral nerves were all intact. The patient was stable at discharge on postoperative day 4 and was discharged to the shelter with 2.4 million U of Bicillin (Wyeth-Ayerst, Philadelphia, PA) × 2 injected intramuscularly at the oral maxillofacial surgery clinic with a follow-up appointment in 5 days for a postoperative review.
Case Report Sir Percival Pott in 1760 talked about Pott's Puffy tumor as “a puffy, circumscribed, indolent tumor of the scalp and a spontaneous separation of the pericranium from the skull under such a tumor [3].” Pott's Puffy tumor is, in fact, a misnomer and is an eponym for frontal osteomyelitis associated with subperiosteal abscess. It is an extremely rare entity, and there have been no published articles presenting this disease after an incident of minor head trauma in an adult. The typical presentation of Pott's Puffy tumor is normally considered similar to that of frontal sinusitis—with organisms such as streptococci, staphylococci, Haemophilus influenzae, and anaerobic bacteria usually are the causative agents—followed by head injury. The differential diagnosis for a patient presenting with persistent frontal sinus pain after head trauma includes subacute sinusitis, nonresolving hematoma, and Pott's Puffy tumor. The symptoms of facial pressure and pain, purulent nasal discharge, nasal congestion, hyposmia, tooth pain, and a poor response to nasal decongestants can help differentiate these entities [5]. The imaging modality of choice for detection of complications has been shown to be CT scanning [6,7]. Subacute sinusitis represents a continuum of the natural progression of acute sinusitis, which lasts for a period of 4 to 12 weeks. It is estimated to affect more than 30 million Americans and is believed to be increasing in incidence [8]. Symptoms of acute sinusitis include nasal congestion, purulent nasal discharge, maxillary tooth discomfort, hyposmia, and facial pain or pressure that is worse when bending forward [5]. Patients with high fever, acute facial pain, swelling, and erythema should be treated for acute sinusitis whether symptoms have been present for at least 7 days. Patients with high fevers and severe headache also warrant immediate evaluation. The finding of abnormal vision, changes in mental status, and/or periorbital edema should lead to a referral to a specialist for the possibility of complications of sinusitis including intracranial and orbital extension. The CT scanning is generally acknowledged to be the imaging procedure of choice [9,10]. Nonresolving hematomas arise most commonly from head injuries. In the United States alone each year, 3% to 4% of persons in the United States (7.5-10 million) sustain head injuries. Approximately 85% of these injuries are minor (lacerations or contusions of scalp) and about 15% are major (concussion, skull fracture, intracranial hemorrhage) [4]. If the hematoma is accompanied by intracranial hemorrhage or increased intracranial pressure, hypertension with bradycardia (Cushing's reflex) is an ominous sign, as well as abnormal respiratory pattern. In theses cases, retinal hemorrhage, gaze deviation, anisocoria, cerebrospinal fluid rhinorrhea or otorrhea, and hearing loss, as well as nausea and vomiting may occur. Osteomyelitis of the frontal bone can present as a complication of frontal sinusitis. It is unusual for this to occur after maxillary sinusitis. Osteomyelitis of the skull is
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thought to occur as a consequence of infection spreading into bone marrow adjacent to the sinuses, and this varies according to age [11]. Bone scanning will detect osteomyelitis but cannot discern from an attack of sinusitis. This may have contributed to the development of osteomyelitis. Various reports have described the surgical treatment of Pott's Puffy tumor as including debridement and removal of the sequestrum. The definitive management of Pott's Puffy tumor involves a combined surgical and antibiotic approach to prevent further suppurative complications. Surgery affords drainage of the abscess and debridement of the osteomyelitic bone [12]. Pott's Puffy tumor is not well highlighted in current emergency medicine literature and may be unfamiliar to emergency physicians. Although this patient had an atypical presentation, this rare entity can be easily missed if not considered early in the diagnosis, leading to serious consequences. Its inclusion in the differential of persistent posttraumatic frontal head swelling in the appropriate setting, along with neuroradiologic investigation, can aid in the diagnosis. Definitive treatment includes prompt surgical intervention along with antibiotics. Gabriel J. Martinez-Diaz BS University of California San Francisco, CA 94110, USA Stanford University School of Medicine Stanford, CA 94305, USA Renee Hsia MD, MSc Department of Emergency Medicine San Francisco General Hospital
University of California San Francisco, CA 94110, USA E-mail address:
[email protected] doi:10.1016/j.ajem.2007.11.038
References [1] Gross T, Kaim AH, et al. Current concepts in posttraumatic osteomyelitis: a diagnostic challenge with new imaging options. J Trauma 2002;52(6):1210-9. [2] Bohm E, Josten C. What's new in exogenous osteomyelitis? Pathol Res Pract 1992;188(1-2):254-8. [3] Pott P. The chirurgical works of Percivall Pott, FRS, surgeon to St Bartholomew's Hospital, a new edition, with his last corrections. 1808. Clin Orthop Relat Res 2002(398):4-10. [4] Jagger J, Levine JI, et al. Epidemiologic features of head injury in a predominantly rural population. J Trauma 1984;24(1):40-4. [5] Shah AR, Salamone FN, Tami TA. Acute and chronic sinusitis. In: Lalwani AL, editor. Current diagnosis and treatment in otolaryngology-head and neck surgery. New York: The McGraw-Hill Companies, Inc; 2008. [6] Harrington PC. Complications of sinusitis. Ear Nose Throat J 1984;63 (4):163-71. [7] Wells RG, Sty JR, et al. Radiological evaluation of Pott's Puffy tumor. JAMA 1986;255(10):1331-3. [8] NIH. Data Book; 1990. p. 90-1261 (Table 44). [9] Osguthorpe JD, Hadley JA. Rhinosinusitis. Current concepts in evaluation and management. Med Clin North Am 1999;83(1):27-41, vii-viii. [10] Zinreich SJ. Rhinosinusitis: radiologic diagnosis. Otolaryngol Head Neck Surg 1997;117(3 Pt 2):S27-S34. [11] Maheshwar AA, Harris DA, et al. Pott's puffy tumour: an unusual presentation and management. J Laryngol Otol 2001;115(6):497-9. [12] McDermott C, O'Sullivan R, et al. An unusual cause of headache: Pott's Puffy tumour. Eur J Emerg Med 2007;14(3):170-3.
