Written by Dr. Noah Trump (PGY3), Dr. Arvind Haran (PGY4), and Dr. Stephen Blumberg
Chief Complaint: Fever, headache, and left orbital swelling
History of Present Illness:
Our patient was first seen in the Pediatric ED 11 days prior to our ED visit for left periorbital swelling. This swelling occurred after seafood ingestion, so swelling was presumed to be due to an allergic reaction. Patient was treated for allergy, observed in the ER and discharged.
3 days later (8 days prior to our ED visit), patient was seen in the emergency department for for congestion, cough, and mild headache. His symptoms were presumed to be due to viral illness. COVID/Flu/RSV testing was negative, so the patient was discharged with antipyretics and return precautions.
On our ED visit, patient reported pain above the left eye that was progressively worsening over the past 3 days. Pain was constant and minimally relieved by acetaminophen or ibuprofen, described as superficial and worse with palpation. His mother reports his forehead and eyelid have appeared more swollen for the past five hours. Pain does not change with eye movement and was associated with left eye blurry vision and photophobia. ROS+ for fever, measured temperature of 101F at home today. Denies neck stiffness, weakness, rash, vomiting, diarrhea, abdominal pain, chest pain, shortness of breath. Vaccines up to date.
Vitals from Today's Visit: HR 109, Temperature 100.2F, BP 132/72 , O2 99% , RR 18
Physical Exam:
GEN: Appears uncomfortable.
HEENT: Exquisitely tender to palpation above L eyebrow without associated erythema or edema. L eyelid mildly swollen, L eye mild ptosis. PERRL, EOM.
NEURO: AOx3. Strength and sensation intact. no facial droop or tongue deviation, intact finger to nose.
Pertinent Lab Data:
WBC 8.7, Hgb 13.5, Hct 39.8, Plt 307
Na 138, K 4.1, Cl 96, CO2 26.9, Cr 1.0, Ca 9.5, AG 15.1
Pertinent Patient Images (Obtained with Permission):
Fig. 1: Patient with periorbital swelling, ptosis, and tenderness above left eyebrow without obvious erythema, fluctuance, or visualizable abscess
Fig. 2: CT Head with IV contrast showing air-fluid levels indicating sinusitis in the frontal, ethmoid, and sphenoidal sinuses. Soft tissue swelling superficial to the left frontal bone consistent with Pott's Puffy Tumor and extension of left frontal sinus disease intracranially with pneumocephalus and subdural empyema
Fig. 3: Left frontal sinus disease with bony rarefaction of the posterior sinus wall and pneumocephalus extending from this region posteriorly
Case Discussion:
Given the patient’s fever and exquisite frontal bone tenderness, CT Head with IV contrast was obtained which showed “soft tissue swelling left forehead consistent with Pott’s Puffy Tumor” and “extension of left frontal sinus disease intracranially with pneumocephalus, subdural empyema, and meningitis.” The patient was started on broad-spectrum antibiotics and neurosurgery and ENT were emergently consulted. MRI brain with and without contrast showed pansinusitis and left frontal subdural empyema with surrounding meningitic changes. Decision was made for emergent endoscopic bilateral sinus surgery and frontal sinusotomy by ENT. Neurosurgical intervention including craniotomy was deferred due to small size of collections and naivety to antibiotic therapy. Patient was then admitted to the PICU and recovered well.
This case demonstrates a deceptively benign presentation of a life-threatening disease that was not obvious in the prior two ED visits. Pott’s Puffy Tumor (PPT) is defined as osteomyelitis of the frontal bone with subperiosteal abscess. It is a rare complication of inadequate treatment of frontal sinusitis which classically presents with frontal bone edema and obvious abscess. Intracranial complications occur due to venous drainage or direct extension, leading to epidural abscess or subdural empyema formation, meningitis, cavernous sinus, dural venous sinus thrombosis, and orbital cellulitis. Can occur in all ages but may show predilection for adolescents due to high vascularity in the frontal and ethmoid sinuses.
Noah's Pearls:
Pott's Puffy Tumor (PPT) may not always present with an obvious abscess on the forehead. The underlying osteomyelitis may only present with exquisite tenderness and minimal swelling.
It is important to keep a broad differential and not anchor on previous evaluations or documentation, especially in a patient with persistent symptoms and repeat visits.
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