Transcript Case Conference

13yo Male with no sig. PMHx
presented to the ED complaining
“there is a bump on my
forehead”
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Duration: 2 days
Localization: Left
forehead
Tender to palpation
Clear nasal
discharge
No medications
No fever, HA, N/V,
Visual changes,
dizziness
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No traumas or bug
bites
Progression:
Worsened over first
day
Additional Hx: 1
month ago had a
“big pimple” in the
same area
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VS WNL
Well appearing
Facial Asymmetry
Palpable 8cm
induration left
forehead
Warm
No erythema
No fluctuance
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No discharge
No Orbital swelling
Eyes: PERRLA, EOMI,
no tenderness
Clear nasal
discharge BL
Tenderness on BL
Paranasal Sinuses
Rest of PE WNL
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Osteomyelitis of the frontal bone with
Subperiostal Abscess, often seen as a
complication of Frontal Sinusitis
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First described in 1760 by Sir Percivall
Pott, patient presented with Subperiostal
Abscess and Extradural Empyema
Frontal Sinusitis, most
common
Trauma
Skin infections/Bites
Intranasal
Cocaine/Methampheta
mine abuse
Mastoiditis
Malignancies
Craniotomy
More common in Males
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Well appearing to Ill appearing
Signs of URI infection anywhere from 2 days to 14 days
Low grade fever 38-38.5C
HA, Nausea, Vomiting
Sinus tenderness
Swelling Forehead, mid forehead more common, with
erythema, fluctuance, and tenderness
Altered Sensorium
Hx of previous Abx is common
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Clinical: High index of suspicion
CBC WBC>15.000, left shift
Elevated ESR/CRP
Elevated WBC and Protein CSF
Imaging:
› US
› Head CT C› Size of the abscess, extent of involvement. Orbit
also should be scanned in the presence of
preseptal cellulitis or in patients in whom vision /
ocular movement is compromised.
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Imaging
› Nuclear Scanning: Delineate Bone infection
› CT C+: Brain involvement
Subdural and subcutaneous
temporal empyema
Frontal and temporal
empyema and fluid
accumulation in frontal sinus
Meningitis
 Venous sinus thrombosis
 Subdural abscess
 Epidural abscess
 Brain abscess
Complications
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Differential Dx
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Preseptal Cellulitis
Septal Cellulitis
 Broad spectrum Antibiotics 6-8 weeks
 Drainage Neurosurgery/ENT
 Riedel’s procedure: This procedure is indicated in patients
with intracranial complications. This procedure involves
complete removal of posterior table of frontal sinus with
cranialization of frontal sinus. This is followed by removal of
anterior table, causing prolapse of forehead skin into the
frontal sinus cavity.
Reconstruction of forehead can be performed using:
1. Split calvarial bone grafts
2. Polymethyl – methacrylate
3. Hydroxyapatite
4. Titanium mesh
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Trephination of Frontal Sinus
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Cranialization of Frontal Sinus
Head CT C-: Soft tissue swelling overlying the
left frontal bone
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A mother brings her 3-year-old daughter in for evaluation. She enrolled
her daughter in child care 1 week ago. Over the past 3 days, the child
has experienced yellowish rhinorrhea and cough. Her appetite has
remained good, and her highest temperature has been 37.3°C. On
physical examination, the child is interactive and playful. Her tympanic
membranes are normal bilaterally, but yellowish rhinorrhea is visible in
both nares. The remainder of the physical examination findings are
unremarkable. You order a sinus radiograph series, which shows bilateral
maxillary mucosal thickening with opacification of the ethmoid sinuses.
Of the following, the MOST appropriate next therapy is:
A. Amoxicillin orally
B. Azithromycin orally
C. Ceftriaxone intramuscularly
D. Observation
E. Trimethoprim-sulfamethoxazole orally
Answer: D
Viral URI
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Rani Haider, Helen; Mayatepec, Hernan; Schaper, Jorg; Vogel,
Markus. Pott's puffy tumor: a forgotten differential diagnosis of frontal
swelling of the forehead. Journal of Pediatric Surgery Vol 47, Issue 10,
October 2012, Pages 1919–1921
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Chaudhary, Subhash; Mogal, Survana; Suwan, Phillip. Pott’s Puffy
Tumor: An Uncommon Clinical Entity Case Reports in Pediatrics Vol
2012 (2012), Article ID 386104
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Vanderveken OM, De Smet K, Dogan-Duyar S, Desimpelaere J, Duval
EL, De Praeter M, Van Rompaey D. Pott's puffy tumour in a 5-year old
boy: the role of ultrasound and contrast-enhanced CT imaging;
surgical case report. B-ENT. 2012;8(2):127-9
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Wald, Ellen. Acute bacterial rhinosinusitis in children: Clinical features
and diagnosis. Up to Date
Thank you…