Download Julie Blacksmith

Pott’s Puffy Tumor Presenting as
Preseptal Cellulitis
Julie Blacksmith, OD
PO Box 362
Sunapee, NH 03782
[email protected]
Richard Frick, OD FAAO
Dorothy Hitchmoth, OD FAAO
Abstract:
I will present a case of Pott’s Puffy Tumor diagnosed via CT scan in a 60 year old
immuno-comprised white male presenting to our clinic with the initial diagnosis of
preseptal cellulitis.
Key words: Pott’s Puffy Tumor, osteomyelitis, preseptal cellulitis, subdural empyema
Outline:
I. Case History
A. 60 year old white male, LR
B. Chief complaint:
1. Swollen and mildly painful to the touch upper left eyelid
2. Began 2 weeks ago and initial presentation lasted x 3-4 days
3. Initial swelling cleared up on its own
4. Reoccurred and had been present x 3 days upon his arrival to the
Emergency Department one day prior to eye clinic visit
5. Mild blurring of vision OS
6. No pain on eye movements OD or OS
7. No diplopia
8. No photophobia OD or OS
C. Ocular history:
1. LEE 1 year ago
a. Near vision only glasses
b. No other remarkable ocular history
D. Medical history:
1. Currently undergoing chemotherapy for Small Cell Lung Cancer
2. Chronic sinusitis
3. Asthma
4. Stable angina
5. Small bowel obstruction
6. Rosacea
E. Medications:
1. Docetaxel 171 mg (75mg/m2) IV over 1 hour - 3 cycles at 3 week intervals
2. Albuterol 90 mcg inhaler bid
3. Gabapentin 1000 mg po tid
4. Lansoprazole 30 mg po qhs
5. Lovastatin 40 mg po qhs
6. Metronidazole cream prn
7. Ibuprofen tid po prn
8. Vicodin 2 tabs q 4-6 h po prn
9. Multivitamin po qd
10. Calcium 600 mg po qd
11. Vitamin E 400 mg po qd
12. B Complex po qd
13. Vitamin C 500 mg po tid
14. OTC Sinus tablet po prn
15. Tylenol 1000 mg po tid.
F. Other Salient Information:
1. Beginning at his initial visit and over the course of 7 follow up visits in 6
weeks, LR underwent 3 courses of antibiotic therapy both intravenously and
orally
2. CT scan of his head and orbits was obtained which led to the ultimate
diagnosis and treatment plan
II. Pertinent Findings
A. Clinical and Physical Findings:
1. VA cc: OD: 20/20 OS: variable over the course of follow-up visits ranging
between 20/20 and 20/252. Gross External Exam: Presentation varied over course of 7 visits
a. Initial visit and Second visit: Swollen and warm to touch LUL and LLL
with mild hyperemia of lids OS and a small, firmer, palpable mass superior
nasal portion of LUL.
b. Third visit: No changes except more tenderness along left eyebrow
than observed previously.
c. Fourth visit: Hard palpable mass 10mm H/5 mm V on LUL. Lesion was
red and painful upon touching it. Ptosis still evident OS with only mild
swelling of LUL evident. No proptosis observed OD or OS
d. Fifth visit: Large, 10 mm x 10 mm x 8 mm, cyst on LUL surrounded by
erythematous area with mucopurulent material actively draining from the
lesion. Ptosis still evident OS with mild periorbital edema OS and no
proptosis OD or OS.
e. Sixth visit: Gross External Exam: Flattening of lesion with scab
overlying harder, palpable mass on LUL. Mild edema around scab on LUL.
Ptosis still evident OS with mild periorbital edema OS and no proptosis OD
or OS.
f. Seventh visit: Further flattening of lesion with small drainage point
on LUL with palpable harder mass underneath. Mild ptosis still evident with
mild edema of LUL. No proptosis OD or OS.
3. Entrance Testing: At all 7 visits
a. PERRL D&C –APD
b. EOMS: SAFE (-)diplopia, (-)pain
c. FCF: FULL OD and OS
d. Exophthalmometry: OD=OS at 18 mm OU
e. Cover test sc: Constant Left XT at distance in all positions of gaze and
Orthophoria at near in all positions of gaze
4. Biomicroscopy:
a. Initial visit through Fifth visit: WNL OU, IOP WNL OU
b. Sixth visit: No changes OD or OS except trace injection of bulbar
conjunctiva OS.
c. Seventh visit: No changes OD or OS except 2+ injection of bulbar
conjunctiva OS and 2- Superficial punctuate keratitis of corneal epithelium
OS.
5. Dilated and Undilated Fundus Exam: At all 7 visits
a. Lens: 1+ NSC OU
b. Vitreous: PVD OU, mild asteroid hyalosis OD
c. Macula: WNL OD, mild ERM with beginning of pseudohole and mild
traction OS
d. ONH: Distinct margins OU, OD: .25 h/v OS: .30 h/v
e. Vasculature: WNL OU
f. Periphery: WNL OU
B. Diagnostic Testing:
1. HVF 24-2: OD: Reliable with no defects, OS: Reliable with no defects.
C. Radiology Study:
1. CT Scan of Head and Orbits: Impression: Soft tissue swelling of the left
eyelid is apparently due to extension of presumed inflammatory process in the
frontal sinus. There is a fenestration of frontal sinus (postoperative change cannot
be excluded) and the frontal sinus is opacified. The sphenoid and both maxillary
antra are nearly obliterated by bony overgrowth, presumably secondary to severe
sinusitis (perhaps from an atypical agent) and there is also significant periosteal
thickening in the ethmoid sinuses. Correlation with previous ENT
history is recommended.
III. Differential Diagnosis
A. Primary: Resistant preseptal cellulitis secondary to immunocompromised state
due to chemotherapy treatment for Small Cell Lung Cancer or secondary to Methicillin
resistant staphylococcus
B. Others:
1. Infectious sebaceous cyst
2. Metastasis to soft tissue around eye from Small Cell Lung Cancer
3. TB Granuloma
4. Fungal infection
IV. Diagnosis and Discussion
A. Diagnosis:
1. Pott’s Puffy Tumor (PPT)
a. Very rare clinical entity characterized by subperiosteal abcess of the frontal
sinus or rarely the maxillary sinus and is associated with osteomyelitis of the
frontal bone (9)
b. In the literature, it has rarely been reported in adults and is rare in general
since the advent of antibiotics
c. Most frequently seen in teenagers, children, and immunocompromised
individuals as a result of trauma or chronic sinusitis
d. Rarely reported following:
i. Intranasal and inhaled cocaine or methamphetamine abuse
ii. Insect bite
iii. Mucormycosis
iv. Dental sepsis (6, 4, 13, 12)
B. Presentation:
1. Variety of initial symptoms
a. Headache
b. Fever
c. Preseptal cellulitis
d. Orbital cellulitis
e. Soft mass on forehead
f. Photophobia
e. Nuchal rigidity
f. Altered mental state
g. Focal neurological signs (14, 7)
C. Causative organisms:
1. Acute sinusitis in adults
a. Haemophilus influenza
b. Streptococcus pneumoniae
c. Streptococcus pyogenes
d. Alpha hemolytic streptococcus
e. Neisseria gonnorhea
2. Acute sinusitis in children
a. Streptococcus pneumonia
b. Branhamella catarrhalis
c. Haemophilus influenza
3. Chronis sinusitis in adults and children
a. Streptococcus
b. Bacteroides
c. Veillonella
d. Fusobacterium
e. Haemophilus influenza
f. Streptococcus viridans,
g. Streptococcus pneumoniae
h. Kleibsella
i. Staphylococcus (1, 8, 13, 2)
j. Rarely fungi such as mucormycosis (6)
4. Most reported cases, the infections are polymicrobial
5. Surface nasal mucosa cultures rarely correlate with sinus aspirates for bacterial
identification (1)
D. Complications:
1. Intracranial spread of infection posteriorly
a. Meningitis
b. Subdural empyema
c. Epidural abcess
d. Cavernous sinus thrombosis
e. Dural venous thrombophlebitis
f. Potential death (1, 15, 5)
2. Intraorbital spread of infection anteriorly
a. Orbital cellulitis
b. Potential blindness (14, 7)
E. Unique features:
1. Patient LR, Pott’s Puffy Tumor masqueraded as a preseptal cellulitis which was
resistant to three courses of antibiotics
2. The lesion and swelling changed in appearance over the course of treatment.
3. CT was needed to make the diagnosis
a. Ordered after the second course of antibiotics failed to provide resolution of
his symptoms
V. Treatment, management
A. Standard treatment:
1. Referral to ENT
2. Possible referral to Neurology
3. Frontal sinus trephination and drainage
4. Antibiotic irrigation of the sinuses
5. Intravenous antibiotics/antifungals for 6 to 8 weeks (11)
a. Ceftriaxone
b. Flucloxacillin
c. Fusidic acid
d. Metronidazole (12)
6. Most infections are polymicrobial, initial treatment is usually broad spectrum
and then tailored to the specific cultured organisms (14)
B. Additional treatment in special cases:
1. Curettage of the osteomyelitic bone
2. Excision of the periosteal granulomatous “puffy” lump (10)
3. Prefabricated titanium implants
a. Enable the reconstruction of the frontal bone after osteomyelitis
b. Prevent compromise of the mechanical stability
c. Provide aesthetically pleasing results (3)
D. Outcomes/Results:
1. Literature case reports show sinus trephination and long-term intravenous
antibiotics have proven successful
2. Patients with serious neurological complications have shown to have full
recovery after appropriate treatment (2)
V. Conclusion
A. Clinical Pearls:
1. If a perseptal cellulitis does not respond to antibiotic therapy, always order a
CT of the orbits and head
2. In patient’s presenting with preseptal cellulitis consider diagnosis of Pott’s
Puffy Tumor if patient is immunocompromised and/or has a history of chronic
sinusitis
3. Early diagnosis and treatment is critical to avoid serious neurological
complications which can result in blindness and/or death
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