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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 Bibliography 1. Backous D: Frontal Sinusitis. Grand Rounds Presentation, 1991. 2. Bambakidis N, Cohen A: Intracranial complications of frontal sinusitis in children: Pott’s puffy tumor revisited. Pediatric Neurosurgery 35:82-9, 2001. 3. Bucheler M, Weihe S, Eufinger H, Wehmuller M, Bootz F: Reconstruction of the frontal bone with individual titanium implants after surgical therapy of osteomyelitis of the frontal bone. HNO 50(4):339-46, 2002. 4. Chandy B, Todd J, Stucker FJ, Nathan CO: Pott’s puffy tumor and epidural abcess arising from dental sepsis: a case report. Laryngoscope 111(10):1732-4, 2001. 5. Davidson L, McComb JG: Epidural-cutaneous fistula in association with the Pott puffy tumor in an adolescent. Case report. Journal of Neurosurgery 105(3 Suppl):235-7, 2006. 6. Effat KG, Karam M, El-Kabani A: Pott’s puffy tumour caused by mucormycosis. Journal of Laryngology and Otology 119(8):643-5, 2005. 7. Hayek BR, Sitole S, Andreoli M, Banich A, Ahmad AZ: Bilateral eyelid edema and orbital cellulitis associated with Pott’s puffy tumor. Ophthalmic Plastic Reconstructive Surgery 23(2):163-5, 2007. 8. Ibarra S, Aguirrebengoa K, Pomposo I, Bereciartua E, Montejo M, Gonzalez de Zarate P: Osteomyelitis of the frontal bone (Pott’s puffy tumor). A report of 5 patients. Enferm Infec Microbiol Clin 17(10):489-92, 1999. 9. Kaabia N, Abdelkafi M, Bellara I, Khalifa M, Bahri F, Letaief A: Pott’s puffy tumor. A case report. Med Mal Infect 37(6):350-3, 2007. 10. Kombogiorgas D, Solanki GA: The Pott puffy tumor revisited: neurosurgical implications of this unforgotten entity. Case report and review of literature. Journal of Neurosurgery 105(2 Suppl):143-9, 2006. 11. McDermott C, O’Sullivan R, McMahon G: An unusual cause of headache: Pott’s puffy tumour. European Journal of Emergency Medicine 14(3):170-3, 2007. 12. Peyman B, Rickman L, Ward D: Pott puffy tumor associated with intranasal methamphetamine. Journal of the American Medical Association 283(10), 2000. 13. Raja V, Low C, Sastry A, Moriarity B: Pott’s puffy tumor following an insect bite. Journal of Postgraduate Medicine 53(2):114-6, 2007. 14. Reynolds DJ, Kodsi SR, Rubin SE, Rodgers IR: Intracranial infection associated with preseptal and orbital cellulitis in the pediatric patient. Journal of the American Association of Pediatric Ophthalmology and Strabismus 7(6):413-17, 2003. 15. Tuon FF, Russo R, Nicodemo AC: Brain abcess secondary to frontal osteomyelitis. Rev Inst Med Trop Sao Paulo 48(4):233-5, 2006.