Introduction Pott’s puffy tumour (PPT) is a rare complication of rhinosinusitis and is characterised by osteomyelitis of the frontal bone and subperiosteal abscess formation. It usually requires urgent neurosurgical and or ENT intervention. In addition to sinus infection, PPT secondary to trauma, craniotomy, otitis media and intranasal cocaine use has also been described.
Presentation A 14-year-old boy presented to the emergency department with confusion, facial pain and frontal headache following a failed one week course of erythromycin for a coryzal illness associated with rigours and high grade fevers. He was noted to have a forehead swelling over the left eye associated with facial tenderness on palpation. A CT scan confirmed features of a PPT showing left frontal subdural empyema with periosteal involvement and frontal ethmoidal sinusitis (Figure 1).
Management A left frontal burr hole surgery with a right frontal sinus trephine and functional endoscopic sinus surgery (FESS) were performed. He was empirically commenced on Ceftriaxone and Metronidazole. Microbiological analysis of drained pus isolated Staphylococcus epidermidis and Parvimonas micra, which were both reported to be sensitive to Ceftriaxone. He received a total of 8 weeks of intravenous therapy with Ceftriaxone followed by 4 weeks of oral Coamoxiclav. Our patient made a remarkable recovery without any neurological complications. Serial MRI scans showed significant interval improvement with minimal reactive dural thickening in the left frontal convexity and a small venous infarct secondary to the extra-axial collection of unclear clinical significance. He continues follow-up with neurosurgery, ENT and paediatrics infectious diseases team.
Discussion PPT has been thought to be rare in the paediatric population. Several case reports and series have been published in recent years suggesting that the condition is being increasingly identified particularly in the adolescent population. CT of the sinuses is suggested as the initial investigation followed by MRI head and MRV if indicated. Prolonged course of antibiotics are usually recommended although there is no data to inform length of therapy. A high index of suspicion and early intervention and management by a multidisciplinary team are of paramount importance for a favourable outcome.
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