PC1195: Potts Puffy Tumor: A Case of Medical Management of This Surgical Emergency

Introduction: Pott Puffy Tumor (PPT) is an osteomyelitis of the frontal bone with associated subperiosteal abscess and forehead and facial edema, which typically presents as a complication of frontal sinusitis or trauma in the teenage years due to an increased flow rate of the diploic veins. PPT has become rare in the antibiotic era, with one retrospective review finding only 93 reported cases from 1998 - 2018. While previously considered a surgical emergency requiring prompt drainage and antibiotic therapy, there have been few cases reported where an exclusively medical approach to treatment of this uncommon complication has been successful.

Case Description: A 13-year-old male with a history of chronic nasal congestion presented with 3 weeks of worsening nasal congestion and rhinorrhea with development of forehead swelling and headache 1 week prior to admission. He was started on amoxicillin for presumed sinusitis, but his forehead edema progressed, prompting presentation to an outside hospital where a CT Head was obtained. Imaging demonstrated a subperiosteal abscess communicating with the frontal sinus without intracranial enhancement (Figure 1). The patient was empirically started on intravenous vancomycin, cefepime, and enteral metronidazole (due to a national shortage of intravenous metronidazole), as well as intravenous dexamethasone and an aggressive nasal regimen with twice daily sodium chloride and budesonide rinses. His forehead swelling resolved over the next 72 hours with gradual improvement of his headache and nasal congestion. Bedside nasal endoscopy demonstrated multiple nasal polyps, an uncommon finding in children, which prompted a negative workup for cystic fibrosis. The patient remained hospitalized for eight days of intravenous antibiotic therapy due to concern for potential complications. In the outpatient setting, he continued intravenous clindamycin, ceftriaxone, enteral metronidazole, and aggressive sinus care for a total of six weeks, with repeat imaging demonstrating almost complete resolution (Figure 2). Throughout, he received multidisciplinary care by otolaryngology, neurosurgery, and infectious diseases services and ultimately, no operative intervention was required.

Discussion: Pott Puffy Tumor can be associated with life-threatening complications including meningitis, epidural, subdural, intraparenchymal, or intraorbital abscess, cavernous sinus or dural venous sinus thrombosis, or orbital cellulitis. However, when identified and treated early with aggressive antibiotic therapy, surgical intervention may be avoided. This case highlights the possibility of utilizing exclusive medical management in patients without intracranial extension, thereby avoiding complications from surgery including facial scars from an external approach or mucosal bleeding from endoscopic intranasal frontal sinusotomy.

Conclusion: As the etiology of PPT is often related to sinusitis and has been found to be polymicrobial when surgical drainage is performed, empiric antibiotic treatment consists of broad-spectrum antibiotics. In uncomplicated cases of PPT, such as with this patient, it may be acceptable to treat with broad-spectrum antibiotics and close monitoring alone without surgical intervention.