Abstract
We report a case of near-complete remodeling of the anterior table of the frontal sinus after treatment for an erosive Pott’s Puffy Tumor. A 61-year-old male presented with progressive swelling of his left forehead. Examination showed a doughy left forehead mass, and a sinus CT showed a lateral left frontal sinus mucocele with complete anterior table erosion. Frontal trephination with marsupialization of the mucocele was performed, and at 8 month follow-up, the patient had no visible defect and only minimally palpable bony defect. The anterior table had remodeled with no additional intervention resulting in a cosmetic outcome imperceptible from the patient’s baseline.
1
Introduction
Pott’s Puffy Tumor (PPT) is a relatively rare entity, described as a subperiosteal abscess of the frontal bone with associated osteomyelitis . The most common causes of PPT are considered frontal sinus infection and trauma. The incidence of PPT has declined with the use of antibiotics, but it can still be dangerous, with significant complications such as epidural, subdural and brain abscess and meningitis. PPT is most common in teenagers and children and associated with more complications in the pediatric population. Fewer than 50 adult cases have been described in the literature in the last 40 years .
Treatments for PPT range from external drainage only, to combined external and endoscopic, to endoscopic-only approaches . Much of the treatment decision depends on the cause and extent of the PPT.
We present a case of an adult PPT with complete frontal sinus anterior table erosion and partial posterior table erosion. The PPT was associated with frontal sinus mucocele and treated with frontal sinus trephination and mucocele marsupialization resulting in full resolution of the PPT and near-complete anterior table remodeling.
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Case report
A 61-year-old African American male presented as an outpatient with a 4 month history of left forehead swelling. He first noted the swelling after a fall from a ladder, but he did not note a head injury at the time. His symptoms upon presentation included headache in the region of the swelling and some non-purulent appearing posterior nasal drainage. He had no history of paranasal sinus disease. Physical exam showed a broad area of edema of the left forehead measuring approximately 5 cm in diameter. The area was soft to the touch and showed no evidence of drainage or fistula ( Fig. 1 ). A non-contrast CT of the sinuses was obtained and demonstrated a superolateral left frontal sinus mucocele causing near-total opacification of the left frontal sinus, gross erosion of the anterior table measuring about 2.5 cm, and some incomplete erosion of the posterior table ( Figs. 2,3 ). The working diagnosis was infected frontal sinus mucocele causing a PPT. The patient was started on amoxicillin/clavulanic acid and prednisone and he agreed to surgical management.
We proceeded to the operating room and performed a left frontal sinus trephination under image guidance. The findings were consistent with the initial diagnosis of PPT with a large mucocele involving the lateral aspect of the left frontal sinus. The natural ostium of the sinus was patent and appeared healthy. The mucocele had a thin bony shell that was breached, revealing thick mucus and notable intracranial pulsations transmitted into the mucocele cavity from the posterior aspect. The anterior table defect was noted. There appeared to be some residual bone along the anterior table but the majority was dehiscent. The bony shelf of the mucocele was widely opened, effectively marsupializing the mucocele into the sinus cavity. The cavity was copiously irrigated. The trephination site was closed primarily, and the patient was discharged on the day of surgery.
At 1 month follow-up, the patient had decreased “spongy” feeling of the left forehead tissue with remaining palpable anteriorly displaced bone. He also had generally decreased left forehead sensation. At 2 month follow-up, the displaced bone gradually had reduced significantly, the “spongy” feeling was absent, and the patient had regained most sensation of his left forehead. At 8 months follow-up ( Fig. 4 ), the left forehead appeared and felt almost completely remodeled to normal contours with an only faintly noticeable defect on palpation.
