A Rare Case of Pott's Puffy Tumor in an Elderly Man with a Background of Schizophrenia

Abstract

Pott's puffy tumor (PPT) was first described by Sir Percival Pott in 1768. It is a life-threating complication of infectious sinusitis, which presents as a forehead swelling due to osteomyelitis of the frontal bone with an associated subperiosteal abscess (Hasan et al, 2019). It is not a true neoplasm; the name "tumor" refers to the swelling that occurs on the forehead as a result of the spread of infection. It is extremely rare in the post-antibiotic era and, when it does occur, tends to affect children and adolescents as the frontal sinus completes its development in preadolescents (Karaman et al, 2008). Very few cases of PPT have been documented in elderly individuals. The authors report the case of Pott's puffy tumor in a 71-year-old man with a background of chronic sinus disease, paranoid schizophrenia, and drug-induced Parkinsonism.An elderly man with a 12-day history of a worsening forehead abscess presented to the emergency department after being referred by his GP following 6 days of unsuccessful antibiotic therapy. On examination, a large, erythematous swelling was noted on his central forehead, measuring 15cm in diameter (Figure 1). The abscess was tender on palpation and fluctuant. There were no visual changes, exophthalmos, enophthalmos, or involvement of the periorbital area. The patient had a normal cranial nerve examination, except for slightly decreased sensation in the central forehead. His vital signs demonstrated tachycardia and, interestingly, he did not have a fever.The patient had a background of paranoid schizophrenia and was taking monthly injections of the typical antipsychotic flupentixol, as well as the anticholinergic procyclidine, for the drug-induced Parkinsonism. The patient lived in sheltered accommodation, smoked 10 cigarettes per day, and consumed cannabis. Recently, to note, the patient had a 2-month stay in a nearby mental health hospital.The patient was admitted, and the abscess was drained and irrigated with saline. Overnight, the abscess re-collected, and bloody nasal discharge was reported. This was re-drained the following morning, and examination after drainage suggested a possible involvement into the frontal sinus. The patient was listed for a CT scan, which demonstrated subcutaneous collection and acute frontal sinusitis complicated by erosion of the anterior wall of the frontal sinus in keeping with osteomyelitis (Figure 2). The CT scan also showed osteitis of the right frontal sinus and bilateral maxillary and sphenoid sinus walls consistent with chronic sinus disease. There was no evidence on CT of intracranial or orbital involvement.The patient was diagnosed with Pott's puffy tumor and referred to otolaryngology colleagues. The patient was commenced on IV piperacillin/tazobactam (tazocin) 4.5g tds and vancomycin 1g tds and listed for Functional Endoscopic Sinus Surgery (FESS).This case highlights the need for early recognition and prevention of benign infections that may subsequently become sinister or fatal. If not identified and managed swiftly, Pott's puffy tumor has a life-threatening sequela due to involvement into the frontal lobes of the brain. Hence, it is importance to have a high clinical suspicion for PPT in the face of medical and psychosocial risk factors. The authors emphasize the importance of a multidisciplinary team approach to managing patients with PPT, with valuable input from otolaryngology, neurosurgery, microbiology, and histopathology enhancing patient care.