A rare case of Pott’s Puffy Tumour with Upper Eyelid Abscess: a report
Dr Monika Teresa Prasetyo at Head and Neck Surgery Study Program, Universitas Brawijaya Malang, Jawa Timur, Indonesia and colleagues have reported a rare case of Pott’s Puffy Tumour. The case has appeared in the Medical Case Reports.
Pott puffy tumour refers to a non-neoplastic complication of acute sinusitis. Pott's puffy tumour is a rare and serious complication of acute or chronic frontal rhinosinusitis which is the osteomyelitis of the frontal bone with associated subperiosteal abscess causing swelling and oedema over the forehead and scalp. Each case has a risk of causing intracranial sequelae and death if not adequately treated.Multidisciplinary management of intravenous antibiotics and aggressive operative management are often required and effective.
According to history, a 21-year-old man came with a headache, especially on the front with a lump on his left forehead since 3 weeks before admitted. The patient was treated by a neurologist for 10 days and received medications in the form of antibiotics (cefixime) and analgesics. The patient feels the headache is gone but the head bump extends to the center of the forehead with swelling and pain in the left eyelid. Patients are advised to an ENT specialist then referred to an ophthalmologist and get antibiotics (ceftriaxone). After 5 days, an ophthalmologist performed incision with the installation of a drain on the left eyelid. The patient was then consulted back into the ENT section. No ear, nose, and throat complaints were obtained. History of old cough, trauma, insect bite. The patient has smoking habits 1 pack per day since approximately 5 years ago.
From the physical examination, the patient's general condition is sufficient, with vital signs within normal limits. Localized status has edema in the frontal region accompanied by tenderness but no hyperemia. The left superior palpebra region appears to be edema and hyperemia with the drain attached. The movement of the eyes can be in all directions and the left orbital visus is within normal limits. There were no neurological disorders.
Based on nasoendoscopy examination, the mucosa of frontal recess and the osteomeatal complex appear to be polypoid, edematous, hyperemic, and with mucopurulent secretions. Head CT Scan with axial incision show opacification in the left and right maxillary sinuses, left frontal sinus and left ethmoid sinus. The CT scan also shows defects of the frontal bone and soft tissue swelling in the extracranial frontal region.
CT scan evaluation is performed with suspicion of sinusitis in left and right maxillary, ethmoid, and frontal sinuses. Visible lytic lesion accompanied by hyperostosis in the anterior wall posterior left frontal sinus, left anterior sinus etmoidalis left the wall, anterior left lateral sinus left sinus wall.
We diagnosed this patient with frontal chronic rhinosinusitis with complications of Pott's puffy tumor. Patients are planned for FESS and joined surgery with the Neurosurgery department for debridement and muscle patch decortication. Patients received levofloxacin and metronidazole for antibiotics.
For debridement and muscle patch decortation, an external approach is made through a bicoronal incision. Visible lytic lesion of the antrum wall of the frontal sinus with fibrotic tissue fills the sinus cavity. Exploration is done on the posterior wall of the frontal sinus and no osteomyelitis is obtained, followed by debridement. The cleansed frontal sinuses are covered with muscle patches taken from the right temporal fascia. Muscle patch closed with bone wax and haemostatic gelatin sponge then the installation of drain and wound incision closed layer by layer.
When FESS is performed, it appears that the mass resembles a polyp filling the left media meatus, especially the superior side, not exceeding the lower limit of the inferior turbinate. The uncinate process appears hyperemic and edema. The masses are cleaned with Blakesley's forceps as clean as possible until the ethmoid bullaes are identified and the tissue taken is sent to the Anatomical Pathology section. Unsinectomy has done with backbiting forceps and maxillary sinusotomi sinistra with J curette, the rest of the tissue is cleansed with microdebrider.
The polyps block the left frontal sinus ostium, cleansed as cleanly as possible and the tissue is taken is sent to the Anatomical Pathology department and then the ager cell is cleansed and the frontal sinus ostium is extended to the anterior side with the sinus drill to the size of the ostium to be adequately assessed.
Two days postoperatively, the drain on the head is released and subjectively the patient feels the headache but can be overcome with analgesics. Vital signs are within normal limits. Minimal edema in the left superior palpebrae with visual acuity within normal limit, the frontal region appears edema with tenderness, in the left nasal cavity appears hyperemic and edema without active bleeding. Our patients were treated with clindamycin 3 × 300 mg orally, intranasal corticosteroids and isotonic nasal irrigation 2-3 times per day.
From the histopathologic examination of the mass, inflammatory polyps with dominant neutrophils were obtained. No growth of aerobic bacterial colonies from a microbiological examination of the frontal and nasal sinus swabs. Virus infections or fastidious organisms cannot be excluded. Nine days post-operatively, subjectively no complaints were received. The frontal region appears edema without hyperemia. The nasal cavity appears minimal edema and hyperemia. Up to the time this case report was made the patient had regular control and no complaints subjectively. Neither hyperemia nor edema appears in the frontal region.