PÁGINA DEL RESIDENTE

What would your diagnosis be?

¿Cuál es su diagnóstico?

Female patient, 21 years old, with a history of bronchiolitis who had undergone surgery ten years previously for frontal bone osteomyelitis as a result of frontal sinusitis associated with a subperiosteal abscess. The onset was characterized by high fever together with greenish, fetid rhinorrhea which did not reduce with antibiotics and corticotherapy. She underwent surgery that included a frontoethmoidectomy with mucosal debridement and cleaning of the left frontal and ethmoidal sinus. After a follow-up period of months she was discharged as it was thought that the condition had been resolved.

She complained of generally feeling unwell, and she had been experiencing blurred vision over the previous two weeks, which did not remit after taking NSAIDs. She reported a concomitant increase in the size of the left frontal region together with pain. On physical examination, the patient was discovered to be feverless, and a frontal left sided swelling that was tender on palpation was noted. Blood tests were carried out that proved to be completely normal, and a Waters radiography showed an area of hyperdenisty by the left frontal region. Frontal sinusitis was diagnosed, and the patient was discharged and given empirical antibiotic treatment by means of amoxicillin caluvulanate. One month later she attended the emergency department with left sided eyelid edema and pain on pressing the orbit. She continued to have frontal non-fluctuating swelling, and there was further left sided swelling above the lid. There was no fever or rhinorrhea. A CAT scan was carried out of the paranasal sinuses that revealed a left frontal sinus occupied by a bone defect by the anterior and posterior wall, as well as an increase in the density of extracranial soft tissue of 1.5 cm in diameter with peripheral enhancement, and which was adjacent to the bone defect of the anterior wall. Hemocultures were taken, and a puncture was carried out of the area affected so that a microbiological study could be carried out. Both were negative and no microorganisms were seen to be growing.

Pott’s Puffy tumor. Recurrence after being asymptomatic for 10 years

Tumor hinchado de Pott. Recidiva tras 10 años asintomático

P. Martos Díaz¹, L. Naval Gías², R. González García¹, M. Mancha de la Plata¹, G. Youn Cho Lee¹, F.J. Rodríguez Campo², J. Sastre Pérez², M. Muñoz Guerra², F.J. Díaz González³

1. Médico Residente.
2. Médico adjunto.
3. Jefe de Servicio. Servicio de Cirugía Oral y Maxilofacial.
Hospital Universitario de la Princesa. Madrid, España

Correspondence

The symptoms described include sinusitis of the frontal sinus that began at the age of eleven because of a subperiosteal abscess, within the context of what is termed "Pott’s Puffy Tumor". This developed into frontal osteomyelitis, which was treated by means of wide spectrum antibiotics and corticotherapy, and then with surgery for debridement of the affected sinuses.

Ten years after the initial symptoms, a recurrence took place, with renewed symptoms of frontal sinusitis. On this occasion, surgical intervention was again decided on, using a bicoronal approach. A bony window was made out using the osteoplastic ostectomy¹ technique by means of which the affected frontal sinus was reached, and ample debridement of the area was carried out. Once the cavity had been cleaned and all the granulation tissue removed, a bone chip graft was obtained from calvarial bone itself and the cavity was completely sealed. Then the bone window was put in place and secured with titanium miniplates.

The histological postoperative study showed the existence of sinonasal bone fragments with chronic dense inflammatory infiltrate with no characteristic specificity. The resected tissue culture was once again negative (fig. 1 y 2).

Discussion

In 1760, Sir Percival Pott described a new entity concerning a subperiosteal abscess associated with osteomyelitis of the frontal bone.² Later, the term Pott’s Puffy tumor began to be used in order to refer to new cases concerning this entity. Since Pott’s Puffy Tumor was first described, a few cases have been reported,^3-5 but since the beginning of the antibiotic era, the number has diminished drastically. Fewer than twenty cases have been published to date,^6,7 and it is currently an entity that has fallen into oblivion given its rare appearance.

This type of lesion is associated mostly with symptoms of frontal sinusitis.^8,9 It has also been described as being associated with previous trauma, although on occasions the patient will not remember this, as the symptoms may arise sometime later. One isolated case has been described associated with the consumption of cocaine.¹⁰ In this case of ours the tumor arose as a result of childhood frontal sinusitis, and no associated trauma was reported. This is the first case described in the literature of recurrence of Pott´s tumor after aggressive surgical treatment, and it is significant that 10 years after having been operated, the tumor reappeared.

With regard to the propagation mechanism, it is thought that this is due to dissemination through the venous drainage systems of the frontal sinus, or because of it extending directly through the bone and that, as a result, symptoms of osteomyelitis and intracranial infection may arise.¹¹

In the cultures isolated in the different cases published, polymicrobial involvement can be observed with a predominance of alpha and beta hemolytic streptococcus, bacteroids and anaerobes,^12,13 Although, in this case of ours, microbiological studies were carried out by means of puncturing the lesion on the operating table as well as previously in the emergency department, the results were negative as no germs could be grown. This is possibly due to the patient having taken a ten day course of amoxicillin clavulanate.

Many of the entities described are associated with considerable osteomyelitis and extensive erosion of the anterior wall, as well as the posterior wall of the frontal sinus. Among the associated complications, orbital cellulitis stands out as it commonly appears, as occurred in our patient. This can arise because of an adjacent infection in the ethmoidal sinus, or as a result of the frontal sinus itself.¹⁴ The most serious complication is however intracranial dissemination triggered by the erosion of the posterior wall of the sinus, and this can give rise to an epidural abscess, subdural empyema and brain abscesses. Lastly, thrombosis in the cavernous sinus is a complication that may arise.¹⁵

During the surgery, some destruction was seen of the posterior wall of the frontal sinus that went through to the dura mater, which was intact. There were no signs of meningeal involvement (fig.3).

After the sinus cavity had been cleaned extensively, which included debridement of the granulation tissue and elimination of the membrane, and given that the cultures previously carried out had been negative, it was decided that the cavity should be completely sealed. For this, we decided to use bone chip graft that was compacted, with the aim of avoiding further recurrence (fig.4).

Various articles stress the importance of removing osteomyelitic bone, as well as the underlying epidural granulation tissue while being careful not to damage the dura mater.^16,17 But in none of these is there any reference to the possibility of sealing the remaining cavity using a bone graft from another site (fig. 5 y 6).

Conclusions

Pott´s Puffy tumor is currently a very uncommon pathology, which has nevertheless to be taken into consideration when symptoms include chronic sinusitis of the frontal sinus associated with osteomyelitis. This is because with an early diagnosis the number of serious intracranial complications that may be associated will diminish. Our approach should be aggressive from the start, with a view to eliminating the infectious foci followed by the debridement and curettage of all the area. Sealing the resulting cavity should be carried out providing the infection is not active, and it should be aimed at producing compact bone in order to avoid a recurrence of the symptoms.

Dirección para correspondencia:
Pedro Martos Díaz.
Hospital de la Princesa. Departamento de Cirugía Maxilofacial.
c/ Diego de León Nº 62. 28006. Madrid, España
Email: plmartos9@hotmail.com

References

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