What is Pott’s Puffy Tumor (PPT)?
1) PPT is a subperiosteal abscess of the anterior wall of the frontal sinus associated with an underlying frontal osteomyelitis. It appears clinically as a localized frontal swelling, and most frequently develops after misdiagnosed or inappropriately treated cases of frontal sinusitis.
2) PPT occurs in patients of all ages, but is more common in adolescents bcs the flow rate in the diploic veins increase during this period.
3) PPT can be a very dangerous complication if frontal sinusitis bcs it can lead to life-threatening complications such as meningitis and epidural, subdural, and brain abscesses.
How is Pott’s Puffy Tumor diagnosed?
1) Dx of PPT is based on history and clinical and radiological findings
2) A CT scan is considered the imaging modality of choice to confirm the dx of PPT
3) MRI is better than CT at detecting intracranial involvement
How is Pott’s Puffy Tumor treated?
1) Surgery
2) Long term intravenous antibiotics
What percentage of patients with Pott’s Puffy Tumor have intracranial complications?
About 72%. This may be as high as 60-100% in pediatric patients
What types of intracranial complications occur in Pott’s Puffy Tumor?
1) Epidural or extradural abscess (47%)
2) Subdural empyema (25%)
3) Brain abscess (12%)
4) Meningitis
5) Cerebritis
6) Cavernous or superior sagittal sinus thrombosis
7) More than one intracranial complication is present in 23% of cases
What pathogens are found in Pott’s Puffy Tumor?
- Streptococci (44%)
2) Staphylococcus
3) Sterile cultures (22.5%) - because most patients received antibiotics prior to surgery
4) Usually polymicrobial
How do you treat Pott’s Puffy Tumor?
1) IV Antibiotic therapy is administered to all patients - the treatment length varied between 10 days and 6 months with the mean duration = 6.5 weeks
2) Intracranial surgery as per Neurosurgery - craniotomy performed for most patients with intracranial complications
3) Endoscopic sinus surgery can be used alone or in combination with external approaches
How does Pott’s Puffy Tumor present clinically?
1) Usually presents with HA, fever, swelling in the periorbital and/or forehead region with an associated purulent or non purulent nasal discharge
2) The presence of aggravating symptoms such as lethargy, alerted mental status, seizures, N/V may indicate possible intracranial involvement
3) The frontal lobe can be clinically silent - should have a high index of suspicion for intracranial involvement
What imaging modalities are used to diagnose Pott’s Puffy Tumor?
1) Contrast enhanced CT scan with brain and bony sequences. This can demonstrate sinusitis, bone erosion, subperiosteal collection, and intracranial extension
- Osteomyelitis is demonstrated as low attenuated areas of lytic bone destruction
2) MRI provides superior soft tissue resolution which demonstates intracranial pathology, dural sinus thrombosis, and bone edema.
- MRV should be added to MRI exam when dural or cavernous sinus thrombosis is suspected
Treatment of Pott’s Puffy Tumor.
PPT requires early and prompt management ot prevent its progression to life-threatening intracranial complications
1) Treatment includes surgical drainage and long-term antibiotics
- Drain subperiosteal abscess
- Eradicate potential infection in the sinus
- Treat possible intracranial complications
2) Should use broad-spectrum abx that penetrate blood/brain barrier and adjust based on any culture/sensitivities that are obtained
- Antibiotic therapy should be continued for at least 6-8 weeks post operatively
Surgery for Pott’s Puffy Tumor.
Surgical intervention can be performed externally, endoscopically, or in combination.
1) Goals of surgery
- Drain abscess material
- Remove osteomyelitic bone
- Remove granulation tissue from the dura to prevent tearing and spreading of infection to the subarachnoid and subdural spaces
2) Surgery has traditionally been conducted using an external approach using a frontal sinus trephine
- Should leave a drain in place
3) PPT can also be managed successfully via an endoscopic approach
- FESS can be used as a stand-alone procedure or in combination with the classic external drainage
4) If there is loculated pus present intracranially, prompt neurosurgical consultation is required
What is the mortality rate of Pott’s puffy tumor?
1) Preantibiotic era = 60%
2) Today - 3.7%
Source: Koltsidopoulos et al.: Pott’s Puffy Tumor In Children, Laryngoscope 130: January 2020, pp 225-231
