Pott’s Puffy Tumor Complicating Frontal Sinus Osteoma - A Case for Combined Approach Surgery

Abstract

Some authors suggest surgical intervention if over 50% of the frontal sinus is occupied by an osteoma [5]. The ideal surgical approach aims to achieve restoration of the drainage pathways, with endonasal, external and combined approaches described. External approaches are associated with risk of sinocutaneous fistulation and sub-optimal management of underlying sinusitis. This has led to interest in development of endonasal approaches. Where access to the anterior table is limited with the endoscope alone, a combined approach is necessary to fully eradicate the disease. Pott’s Puffy Tumor (PPT) describes a subperiosteal abscess overlying frontal bone osteomyelitis which presents as a painful, fluctuant forehead tumor. It is a rare complication, its most common cause being frontal sinusitis. One-third of PPT is associated with lifethreatening intracranial complications [6]. Causative organisms are those frequently implicated in chronic rhinosinusitis: streptococci, staphylococci and anaerobes [7]. Optimum management involves draining the collection, restoring sinus ventilation, debriding the osteomyelitic bone and granulation tissue and protracted antibiotic therapy guided by microbiologist advice [8]. We present the first case of Pott’s puffy tumor caused by a frontal sinus osteoma and describe the use of a combination of external and endoscopic approaches in managing this condition. The challenge in both this case, and in successful management of frontal sinus osteoma and PPT, is eradication of the disease, restoration of sinus ventilation and prevention of recurrence – a case for combined approach surgery.