Recurrent Pott’s Puffy Tumor in a Child with Frontonasal Dermoid: An Unusual Presentation

Introduction: Pott’s puffy tumor is defined as osteomyelitis of the skull with subperiosteal abscess resulting from either trauma or frontal sinusitis. It was first described by Sir Pervical Pott in relation to forehead trauma and early sinusitis in 1768 and 1775, respectively. It is reported to be more prevalent in adolescents due to peak of vascularity in diploic circulation during adolescence. Herein, we describe a case of Pott’s puffy tumor in a 21-month-old child, one of the youngest patients reported in literature to have developed this complication. Also, our case was unique as our patient had a frontonasal dermoid which provided a port of entry for infection and needed resection to prevent recurrences.

Case Description: A 21-month-old male, presented with swelling of forehead extending to the right periorbital area, preceded by a history of nasal congestion and minor head injury. On examination, he was noted to have significant edema with induration, erythema and warmth over the central forehead and right periorbital area, with inability to open the right eye. There was a dimple noted over the nasal bridge with a hair protruding out and exuding sebaceous discharge. Labs were remarkable for leukocytosis and elevated CRP. CT head and orbit was showed large inflammatory process involving frontal region with bony destruction of anterior frontal cortex as well as right parasagittal upper nasal bone suggestive of Pott’s puffy tumor and an infected frontonasal dermoid (image 1). Incision and drainage was performed and cultures were collected. Ceftriaxone, Vancomycin and Metronidazole were started for broad spectrum antibiotic coverage. The wound culture grew E.coli and Streptococcus intermedius susceptible to Ceftriaxone and Clindamycin, which were continued for a total of 6 weeks. He initially improved but had recurrence of the abscess (image 2) after 5 weeks of IV antibiotics, requiring immediate incision and drainage. The dermoid was urgently resected as it was the suspected source of persistent infection and recollection of abscess. New wound cultures remained sterile. He was continued on oral Clindamycin for 8 weeks post dermoid resection.

Discussion: Pott’s Puffy tumor has been reported in all age groups between 23 months and 83 years, but more commonly in adolescents. It frequently follows frontal sinusitis but can also follow trauma. CT maxillofacial with contrast is the diagnostic modality of choice. The management involves drainage of the abscess and resection of the affected bone followed by 6-8 weeks of targeted IV antibiotics.

Conclusion: Pott’s Puffy tumor is a rare but potentially life-threatening condition requiring a multidisciplinary approach for appropriate management. A meticulous search for frontonasal dermoid is warranted when the infection recurs or fails to clear despite adequate treatment.