Pott s Puffy Tumor. Shahad Almohanna 15/1/2018

Transcription

1 Pott s Puffy Tumor Shahad Almohanna R2 15/1/2018

2 Definition First described in 1760 by Sir Percival Pott. s he originally suggested that trauma of the frontal bone was causative for this lesion, but later, he considered frontal sinusitis as the reason for this pseudotumor. In 1775, he described a case of frontal sinus infection causing an indolent puffy swelling of the forehead or subperiostal abscess leading to that name. characterized by a subperiosteal abscess associated with frontal bone osteomyelitis. It is usually seen as a complication of frontal sinusitis.

3 Epidemiology Due to antibiotics era it s a rare complication, the exact incidence however, is not known, only case series and case report found in literature. Male have larger frontal sinuses when compared to females, this may explain the higher incidence of frontal sinusitis and its complications in males. All age groups and it is most frequently noted in adolescents, due to increased vascularity and increase in size of sinus in that age group. Only 18 cases of Pott s puffy tumor have been previously reported in adults >15 years of age.

4 Etiology Complication of frontal sinusitis. Direct trauma to the frontal bone. Following insect bite has also been described. Secondary to allergic fungal sinusitis of frontal sinus.

5 Pathophysiology The venous drainage of frontal sinus mucosa, marrow cavity and frontal bone is through the common valveless diploic veins. This pattern of venous drainage allows the spread of frontal sinus infection into the Haversian system of inner and outer tables of frontal bone. This local suppuration causes local demineralization and necrosis of frontal bone. The purulent material comes out and gets collected underneath the periosteum. This subperioteal collection along with surrounding granulation tissue and edema manifests as swelling over the forehead By direct extension, which is possible in three directions: through posterior wall causing epidural empyema or abscess, subdural empyema, brain abscess or meningitis through the anterior wall causing a PPT. through the inferior wall with orbital complications

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7 Presentation Frontal scalp swelling Headache Fever Nasal drainage Frontal sinus tenderness

8 Presentation Neurologic and intracranial complications in up to 85% of patients. Epidural extension presents with periorbital soft tissue swelling and an intact neurological examination. Brain abscesses or subdural empyem as more commonly have neurological findings like, altered mental status, slurred speech, meningitis sings Examination: frontal swelling with cellulites Endoscopic finding of edema, discharge, polyps. Eye examination and neurological exam.

9 Gildener-Leapman, N. and Lin, A. (2012). Pott's puffy tumor in a 5-year-old male and a review of the literature. International Journal of Pediatric Otorhinolaryngology Extra, 7(2), pp

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11 Microbiology The organisms most commonly observed in Pott s puffy tumor specimens include Staphylococcus aureus, Streptococcus sp. and anaerobes from the oral cavity. Two cases due to Haemophilus influenzae. The cultures may be negative when previous antibiotics are instituted.

12 Diagnosis Leukocytosis and elevated markers of inflammation like ESR and CRP. Gold standard contrasted CT scan: Extracranial fluid collection adjacent to the frontal sinuses or frontal bone. Bony erosions. Sinusitis.

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15 Diagnosis MRI should be performed to assess the extent of disease. Evaluating for intracranial complications. It has a higher sensitivity for detection of small extra-axial collections and for detection of leptomeningeal enhancement, as seen in cases of meningitis.

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17 Blumfield, E. and Misra, M. (2011). Pott s puffy tumor, intracranial, and orbital complications as the initial presentation of sinusitis in healthy adolescents, a case series. Emergency Radiology, 18(3), pp

18 Treatment Treatment is medical and surgical. Broad spectrum intravenous antibiotics with good penetration in CNS and anaerobic coverture must be instituted for at least 6-8 weeks. most commonly used are clyndamycin, ceftriaxone, metronidazole,vancomycin. The use of oral corticosteroids is common but debated, and the literature does not definitively support that practice except in the presence of nasal polyps or other signs of advanced inflammation.

19 Treatment Surgical management consist of frontal sinus drainage, removal of necrotic bone and granulation tissue and ensuring ventilation of frontal sinus. Frontal sinus drainage can be accomplished by external or endoscopic or combined approach. Externally by percutaneous frontal sinus trephination, external frontoethmoidectomy Associated intracranial collections are also evacuated and debrided by craniotomy.

20 External approach: Though the external approach provides direct visualization of frontal sinus and helps immediate drainage of subperiosteal abscess, it is associated with facial scars. Currently this approach is reserved for those patients who have an obstruction of the frontonasal region which cannot be encompassed endoscopically.

21 Trephination

22 External frontoethmoidectomy

23 ENDOCSOPIC Endoscopic approach: Less morbidity, shorter convalescent period and no external facial scar. The main limitation of endoscopic approach is increased risk of mucosal bleeding and tissue edema in presence of acute infection which compromises the visualization.

24 Parida, P., Surianarayanan, G., Ganeshan, S. and Saxena, S. (2012). Pott's puffy tumor in pediatric age group: A retrospective study. International Journal of Pediatric Otorhinolaryngology, 76(9), pp

25 Parida, P., Surianarayanan, G., Ganeshan, S. and Saxena, S. (2012). Pott's puffy tumor in pediatric age group: A retrospective study. International Journal of Pediatric Otorhinolaryngology, 76(9), pp

26 Leong, S. (2017). Minimally Invasive Surgery for Pott s Puffy Tumor: Is It Time for a Paradigm Shift in Managing a 250-Year-Old Problem?. Annals of Otology, Rhinology & Laryngology, 126(6), pp

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28 This systematic review of 29 cases has demonstrated the safety and efficacy of endonasal surgery in the management of PPT. While the extent of infection and frontal sinus surgery varied in these cases, it would appear that either frontal sinusotomy or balloon sinuplasty was sufficient to reestablish drainage of the frontal sinus during the acute phase of the infection. None of these cases resulted in disease progression (eg, development of frontocutaneous fistula), recurrent infection, or abscess formation necessitating external drainage. It should be remembered however that opening of the frontal sinus did not obviate the need for long-term antibiotics.

29 References Kombogiorgas D, Solanki GA (2006) The Pott puffy tumor revisited: neurosurgical implications of this unforgotten entity. Case report and review of the literature. J Neurosurg 105(2Suppl): McDermott C, O Sullivan R, McMahon G (2007) An unusual cause of headache: Pott's puffy tumour. Eur J Emerg Med 14(3): Babu RP, Todor R, Kasoff SS. Pott s puffy tumor: the forgotten entity. J Neurosurg 1996;84: Blumfield, E. and Misra, M. (2011). Pott s puffy tumor, intracranial, and orbital complications as the initial presentation of sinusitis in healthy adolescents, a case series. Emergency Radiology, 18(3), pp Haider, H., Mayatepek, E., Schaper, J. and Vogel, M. (2012). Pott's puffy tumor: a forgotten differential diagnosis of frontal swelling of the forehead. Journal of Pediatric Surgery, 47(10), pp Verma, R. and Behera, S. (2017). Endoscopic management of Pott's puffy tumour - Still a common entity in-developing country a case series of three patients: Our experience. International Journal of Pediatric Otorhinolaryngology Extra. Collet, S. (2009). A Pott's puffy tumour as a late complication of a frontal sinus reconstruction: case report and literature review. Rhinology Journal, 47(4). Haider, H., Mayatepek, E., Schaper, J. and Vogel, M. (2012). Pott's puffy tumor: a forgotten differential diagnosis of frontal swelling of the forehead. Journal of Pediatric Surgery, 47(10), pp Jung, J., Lee, H., Park, I. and Lee, H. (2012). Endoscopic Endonasal Treatment of a Pott's Puffy Tumor. Clinical and Experimental Otorhinolaryngology, 5(2), p.112. Parida, P., Surianarayanan, G., Ganeshan, S. and Saxena, S. (2012). Pott's puffy tumor in pediatric age group: A retrospective study. International Journal of Pediatric Otorhinolaryngology, 76(9), pp

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