Acute Frontal Sinusitis Research Articles

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

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.

Early experience with feasibility of balloon sinus dilation in complicated pediatric acute frontal rhinosinusitis.

Background/ObjectiveComplicated acute rhinosinusitis in the pediatric population is an uncommon problem that may affect the orbit or brain and is life‐threatening. This condition requires surgical intervention with endoscopic sinus surgery for source control, and prior studies have demonstrated the safety of balloon sinuplasty in chronic frontal sinusitis.Methods/ResultsWe present our approach with a balloon sinus dilation hybrid procedure to resolve four distinct types of complicated acute frontal sinusitis in pediatric patients, including intracranial manifestations, intraorbital complications, and recurrent disease. All four patients were able to be managed operatively with frontal balloon sinuplasty.ConclusionsPrior efficacy has been demonstrated for chronic frontal sinusitis in the pediatric population. We demonstrate that frontal balloon sinuplasty is also feasible in the proper clinical setting for acute frontal sinusitis, even in the presence of regional complications or recurrent disease.Level of Evidence4

Very painful acute frontal sinusitis revealing granulomatosis with polyangiitis

IntroductionGranulomatosis with polyangiitis (GPA) is a necrotizing vasculitis of small and medium-sized vessels comprising inflammation of the vessel wall and perivascular and extravascular granulomas, frequently presenting in the form of chronic sinusitis. ObservationWe report the case of a 27-year-old man who presented with very painful acute frontal sinusitis that was managed medically and surgically. The symptoms rapidly recurred despite treatment and CT scan demonstrated diffuse thickening of the sinus mucosa. Anti-proteinase 3 ANCA were positive. Biopsy of a pulmonary nodule confirmed the diagnosis of GPA. The patient was treated with corticosteroids in combination with rituximab, resulting in improvement of the clinical, laboratory and CT signs. DiscussionIn the presence of persistent, acute, localized sinusitis despite appropriate treatment, associated systemic signs and/or the presence of other signs suggestive of GPA, the ENT surgeon must request a targeted work-up. In the absence of treatment, GPA can be fatal within a few months. However, with currently available treatment, remission is obtained in 80% of cases with a 75% 10-year survival rate.

A-69Comprehensive Neuropsychological Evaluation in a Child with Subdural Empyema Secondary to Acute Frontal Sinusitis: A Case Study

A-69Comprehensive Neuropsychological Evaluation in a Child with Subdural Empyema Secondary to Acute Frontal Sinusitis: A Case Study

Acute frontal sinusitis with intracranial and extracranial infection: report of two cases

Acute frontal sinusitis with intracranial and extracranial infection: report of two cases

Endoscopic management of Pott's puffy tumour - Still a common entity in-developing country a case series of three patients: Our experience

Abstract Pott's puffy tumour is a lesser known clinical entity usually seen as complication of frontal sinusitis or trauma to frontal bone. Patients typically present with fluctuant swelling of the frontal region. It can lead to significant morbidity if not diagnosed and treated promptly. We herein present a series of three cases with diagnosis of Pott's puffy tumour, two cases following acute bacterial frontal sinusitis and third case presenting as complication of allergic fungal sinusitis. We discuss the presentation, diagnostic and treatment of Pott's puffy tumour.

Minimally Invasive Surgery for Pott's Puffy Tumor: Is It Time for a Paradigm Shift in Managing a 250-Year-Old Problem?

The aim of this study was to review the clinical outcomes and efficacy of endoscopic sinus surgery (ESS) in the management of Pott's puffy tumor (PPT). Literature PubMed review using a combination of MeSH terms and keywords was undertaken, combined with a single surgeon case series of 3 patients. A total of 29 (20 males, median age 25 years) cases were reviewed. The most common etiology was acute frontal sinusitis (62%), followed by a history of chronic rhinosinusitis (28%). Two patients presented with concomitant preseptal cellulitis and cutaneous fistula each, while another had pneumocephalus. The majority of cases (59%) had Draf 1 procedure. Three cases had Draf 3 procedure. Five cases were successfully treated by sinus balloon sinuplasty. Postoperatively, most patients had either oral or intravenous antibiotics of varying duration. There were no further complications following ESS. Both fistulas healed without requiring surgical debridement or closure. Some PPT cases can be managed endoscopically. The availability of powered angled instruments, high-definition video, and image guidance systems have provided the modern otolaryngologists with a credible alternative to traditional techniques. Furthermore, improved bioavailability of modern antibiotics may obviate the need for craniotomy and external drains.

Pott’s Puffy tumor and intracranial complication developing secondary to acute frontal sinusitis: A case report

Pott’s Puffy tumor and intracranial complication developing secondary to acute frontal sinusitis: A case report

Acute Bacterial Sinusitis in Children

On the basis of strong research evidence, the pathogenesis of sinusitis involves 3 key factors: sinusostia obstruction, ciliary dysfunction, and thickening of sinus secretions. On the basis of studies of the microbiology of otitis media, H influenzae is playing an increasingly important role in the etiology of sinusitis, exceeding that of S pneumoniae in some areas, and b-lactamase production by H influenzae is increasing in respiratory isolates in the United States. On the basis of some research evidence and consensus,the presentation of acute bacterial sinusitis conforms to 1 of 3 predicable patterns; persistent, severe, and worsening symptoms. On the basis of some research evidence and consensus,the diagnosis of sinusitis should be made by applying strict clinical criteria. This approach will select children with upper respiratory infection symptoms who are most likely to benefit from an antibiotic. On the basis of some research evidence and consensus,imaging is not indicated routinely in the diagnosis of sinusitis. Computed tomography or magnetic resonance imaging provides useful information when complications of sinusitis are suspected. On the basis of some research evidence and consensus,amoxicillin-clavulanate should be considered asa first-line agent for the treatment of sinusitis.

Pott puffy tumor in an unusual location

Pott puffy tumor is almost always associated with an outward extension of suppurative acute frontal sinusitis. Pathogenesis includes osteomyelitis of the frontal bone with local spread of the infection to the outer cortex and termination of the suppurative process in a frontal subgaleal abscess. An unusual ectopic location of Pott puffy tumor is the tempo-parietal subgaleal space, located exterior to the squamous portion of the temporal bone. In this location, Pott puffy tumor is considered a suppurative complication of otomastoiditis. Reported here is a 4-year-old boy who developed amoxicillin-resistant acute otitis media, silent mastoiditis, temporal bone subperiosteal abscess, subgaleal abscess, and an epidural abscess. He had several fenestra of the tegmen mastoideum as a result of osteiitis of the temporal bone, which we believe permitted spread of the oto-mastoiditis to temporal bone, subgaleal space, and epidural space. Surgical specimens obtained from the middle ear and subgaleal abscess after 24-hours of intravenously-administered combination antibiotic therapy did not reveal any aerobic or anaerobic bacterial pathogens. This is only the second such pediatric case that we found during a careful search of the literature.

Pott's puffy tumor in pediatric age group: A retrospective study

ObjectiveTo study the etiology, clinical features and treatment outcomes of pediatric Pott's puffy tumor (PPT). MethodsThis retrospective study was carried by reviewing medical case record of pediatrics PPT cases admitted to our hospital from January 2010 to august 2011. Data regarding the patient's demographic details, presenting symptoms and signs, etiology, laboratory findings, imaging findings, management, complications and outcomes of treatment were collected and analyzed. ResultsA total of five cases of PPT were found. Three were male and two were female with a mean age of 11.6 years. All patients presented with headache, fever and tender forehead swelling. Nasal polyps and discharging sinuses over forehead were present in one case and one case had preseptal orbital cellulites in addition to PPT. None of the patient had intracranial complications. Three cases (60%) were secondary to acute frontal sinusitis, one case was as complication of chronic sinusitis and one case was because of trauma. Contrast enhanced Computerized tomography (CECT) demonstrated features of acute sinusitis in 3 cases, sinonasal polyp in one, fracture of anterior table of frontal bone in one case, subperiosteal collection and erosion of anterior table frontal bone in all cases. All patients required surgical intervention; Endoscopic approach 2 cases (40%), combined approach in 2 cases (40%) and external approach in one case (20%) in addition to aggressive antibiotic treatment. There was purulent discharge in frontal sinuses in all cases.In 2 cases (40%), culture of pus drained during surgery was positive; one case methicillin resistant Staphylococcus aureus sensitive to vancomycin, other Pseudomonas aeruginosa sensitive to ceftazidime and amikacin. All cases improved with treatment. There were no postoperative complications or facial cosmetic deformity except facial scar in three cases. The average hospital stay was two weeks and ranged from 10 days to 21 days. All patients received antibiotics for 6–8 weeks to treat osteomyelitis of the frontal bone. The average length of follow up was 9 months (range 6–18 months). All patient are doing well and are under regular follow up. ConclusionsPPT is a complicated infection of frontal sinusitis and trauma that requires broad spectrum antibiotics and surgical treatment. Diagnosis is made by high clinical suspicion of this condition and confirmed by CECT. Early treatment results in favorable outcomes and decreases the risk of further complications.

Clinical application of Draf IIb frontal sinusotomy and it's modified procedures

To summarize the follow-up outcomes of Draf IIb frontal sinusotomy and it's modified procedures, and to discuss the surgical indications and prognostic factors. Thirty-two patients treated between 2004 and 2010 were enrolled in this study. There were 15 patients for recurrent frontal inverted papilloma (IP), 6 for mucocele, 4 for recurrent frontal sinusitis, 3 for osteoma, 2 for meningoencephalocele with cerebrospinal fluid rhinorrhea, 1 for meningoencephalocele alone and 1 for acute frontal sinusitis. All patients underwent preoperative paranasal sinus computed tomography (CT) scans. Patients with tumor accepted magnetic resonance imaging (MRI). The patients with meningoencephalocele and cerebrospinal fluid rhinorrhea received magnetic resonance cisternography (MRC). The Draf IIb frontal sinusotomy and it's modified Draf IIb-1-3 procedures were applied endoscopically under general anesthesia mainly by high speed bur and power system. The postoperative CT scan was obtained as a base line for follow-up 1 week after the operation. Postoperative follow-up was performed under endoscope. Among 19 cases of Draf IIb, 12 were recurrent IP of frontal sinus, 4 were mucocele, 2 were recurrent frontal sinusitis and 1 were osteoma. Five cases received Draf IIb-1, 2 for each recurrent IP of frontal sinus and recurrent frontal sinusitis and 1 for osteoma. Six cases received Draf IIb-2, 3 for meningoencephalocele, 1 for each IP, acute frontal sinusitis and osteoma. Two cases received Draf IIb-3 were mucocele. The follow-up ranged from 8 to 73 months. Twenty-two cases of the frontal nepostium were widely opened, 7 were stenosis and 3 were closed. Revision surgery was seen in 2 cases with IP. All of them had no complications. The Draf IIb frontal sinusotomy and it's modified procedures are suitable for complex frontal sinus disease, which can be selected according to pathological and anatomical features, and have a good prospect for clinical application.

Balloon sinuplasty in acute frontal sinusitis

Balloon sinuplasty has been licensed for the treatment of chronic rhinosinusitis since 2006. Balloon dilation enlarges the sinus ostium by effecting tiny fractures of the surrounding bone and compressing soft tissue such that no mucosa is removed. We believe this to be the ideal technique for achieving drainage of an acutely infected frontal sinus when surgical intervention is required. We report the application of this new technique in a 32-year-old female with acute frontal sinusitis. The frontal sinus was successfully cannulated and drained. Post-operative irrigation was achieved using a modified Vortex catheter.

A Pott's puffy tumour as a late complication of a frontal sinus reconstruction: case report and literature review

A Pott's Puffy Tumour (PPT) is a rare clinical entity, which, traditionally has been described as an acute abscess with periosteitis secondary to osteomyelitis of the external table of the frontal bone of the skull, complicating an acute frontal sinusitis. The aim of this article is to present a case of progressively evolving PPT, which emerged during the course of a common rhinitis, in a patient who, thirty years previously, had undergone a reconstruction of the frontal sinus involving osteosynthesis. The patient was treated with antibiotic therapy coupled with external access surgery using the Cairn Unterberger approach. This allowed the drainage of pus, the removal of infected osteosynthetic material and a complete debridement of osteomyelitic bone from the affected area. Frontal sinus obliteration was undertaken using methyl methacrylate, preferable in this case to hydroxyapatite, due to the direct communication with the neighbouring sinus cavities and the presence of defective bone in the superior orbit. A review of literature available on Medline up to January 2008 reveals that this is the third published case of PPT complicating a frontal reconstruction.

Intracranial complications of sinusitis: what is the role of endoscopic sinus surgery in the acute setting

Objective Intracranial complications of sinusitis (ICS) are uncommon in the antibiotic era. The role of neurosurgical drainage of ICS is fairly well established, but the role for acute surgical intervention for the sinus disease is not well defined. We retrospectively reviewed our experience with ICS to see if we could identify the role and effectiveness of endoscopic sinus surgery (ESS) in the acute setting of ICS. Methods The study used a retrospective review of patients presenting to a tertiary care academic medical center for a 6-year period. Results Twenty-three patients were identified with ICS, including epidural (8), subdural (10), intracerebral abscesses (2), and meningitis (3). Males were more affected than females (7:1). Twenty patients were 21 years old or younger. Twenty-two patients (96%) had radiologic evidence of frontal sinusitis with prefrontal or frontal lobe ICS at presentation. Medical therapy alone was successful in avoiding craniotomy in only 3 of 8 cases. Endoscopic sinus surgery and intravenous antibiotics as initial treatment was successful in avoiding craniotomy in only 1 of 6 patients. Of 23 patients, 18 underwent neurosurgical procedures—9 emergent procedures for abscesses more than 1 cm and 9 delayed procedures for persistent disease despite ICS less than 1 cm at presentation. Conclusions Intracranial complications of sinusitis usually result from indirect spread of acute frontal sinusitis. The role of ESS in the initial treatment of ICS is not clear. In our series, ESS did not appear to alter the need for neurosurgical intervention, which was ultimately necessary in most patients with ICS, even with lesions less than 1 cm.

Sinus headaches: avoiding over- and mis-diagnosis

‘Sinus headache’ is a term used by many patients and primary-care physicians and, contrary to popular belief, sinus headaches are uncommon. Headaches that are due to sinusitis are confined to a minority of patients who have acute frontal sinusitis or sphenoiditis. The International Headache Society classification is robust in qualifying the term sinus headache and says that “chronic sinusitis is not validated as a cause of headache and facial pain unless relapsing into an acute stage”. The vast majority of people who present with a symmetrical frontal or temporal headache, sometimes with an occipital component, have tension-type headache. Unilateral, episodic headaches are often vascular in origin. The idea that sinusitis can trigger migraine is misplaced, as the whole symptom complex is vascular and coexisting nasal congestion is due to vasodilation of the nasal mucosa that is sometimes part of the vascular event. The use of nasal endoscopy and imaging of the paranasal sinuses have advanced our appreciation that these patients are suffering from a vascular event. When these patients are asked to attend a clinic when they are symptomatic, the vast majority are found not to have a sinus infection. Sinusitis rarely causes headache, let alone facial pain, except when there is an acute bacterial infection when the sinus in question cannot drain, and it is usually unilateral due to increased pressure and inflammation caused by pus trapped within the sinus cavity. These patients usually have a history of a viral upper respiratory infection immediately before this and they have pyrexia with unilateral nasal obstruction. The vast majority of patients with acute sinusitis respond to antibiotics. Recurrent bacterial sinusitis is rare and anyone with more than two episodes of genuine bacterial sinusitis in 1 year should be investigated for evidence of poor immunity. Patients with chronic bacterial sinusitis rarely have any pain unless the sinus ostia are blocked and their symptoms are then the same as in acute sinusitis. Within the medical literature, there are texts that report that sphenoid sinusitis can cause headaches and, as with other acute sinus infections, intracranial or ophthalmolgical complications can occur. First, acute sphenoid sinusitis is rare and second, most of these patients respond to antibiotics. Batotrauma can cause short-lived pain in the sinus involved but there is always a clear history associated with diving or flying and, as the pressure within the sinus equalizes, the pain resolves within a few hours. Headaches are rarely due to sinusitis.

Complications of acute frontal sinusitis: a retrospective study

Even though being a rare condition in the era of antibiotic treatment, complications of acute frontal sinusitis still pose a potentially life-threatening problem. We present a clinical case series using a combined surgical approach. Within a 7 year period, all patients with a suppurative complication of an acute frontal sinusitis were included into this retrospective study and evaluated concerning histories, diagnostic and therapeutic procedures and achieved outcomes. Twelve patients (11-74 years) were identified; this corresponds to 0.3% of all patients that have undergone paranasal sinus surgery and 15.4% of all patients with infectious complications of sinusitis. The cases could be subdivided as follows: intracranial complications (4/12), osteomyelitis of the frontal bone (4/12), frontal/orbital soft tissue involvement (3/12) and endoluminal empyema (1/12). These were all correctly diagnosed by CT and (especially in the cases of intracranial complications) MRI. The microbiological spectrum comprised mostly non-multiresistant Staphylococci and Streptococci. All patients received aggressive antibiotic and combined surgical treatment. Within a mean follow up period of 32 months, the disease-related mortality and the rate of severe long-term ailment was 0%. If detected and treated early, both long-term morbidity and mortality can be minimised. A close cooperation with the related specialties (neurosurgery, ophthalmology, radiology) is thereby of utmost importance.

Subduralempyem als Komplikation einer akuten Sinusitis frontalis auf dem Boden eines Stirnhöhlenosteoms

Osteomas of the paranasal sinuses are benign, slow-growing bone tumours with preferred localization in the frontal sinus. They often remain asymptomatic and are found by chance in x-ray examination. Clinical manifestations include headache and orbital complications. We describe the case of a 54-year-old male patient who, based on an osteoma of the frontal sinus, developed an acute frontal sinusitis complicated by subdural empyema. Therapy consisted of two operative interventions. Aetiogenesis of paranasal osteomas is still unclear. Inspite of their slow growth, these tumours can lead to fulminant clinical situation. Choice of operative procedures depends on size and localization of the osteoma. Endocranial complications caused by obstructing osteoma of the frontal sinus must be considered.

鼻腔サルコイドーシス例

Although sarcoidosis is a systemic disease, the involvement of the nasal cavity is fairly uncommon. We present a 27-year-old female whose final diagnosis was nasal sarcoidosis. Nasal obstruction was the sole symptom at her first presentation. She underwent deviatomy of the nasal septum and submucosal turbinectomy. The pathological findings suggesting sarcoid granulomatosis indicated a whole body examination. No lesion in the lung, eye and skin was found at that time. Because of her deteriorating nasal lesions such as acute frontal sinusitis and recurrence of the nasal obstruction, she underwent another biopsy about a 18 months after the first surgery. The pathological findings suggested sarcoid granulomatosis and a second whole body examination was performed. The presence of skin, eye and chest lesions in the examinations lead to the final diagnosis of sarcoidosis originating from the nasal cavity. Treatment with local steroids decreased her symptoms. A close follow-up was planned due to the chronic and progressive course of the lesions of her nasal cavity.

Subdural empyema as a complication of sinusitis in the pediatric population

Sinusitis is a rare cause of intracranial infection in children. While intracranial complications of sinusitis are rare, the morbidity and mortality remain high. Subdural empyema is recognized as the most common sinogenic intracranial complication. We undertook a review of our cases of subdural empyema and other intracranial complications of sinusitis over the past 8 years at a busy inner city hospital. Our intent was to identify factors that may predispose children to these serious complications. A retrospective chart review was conducted using ICD-9 codes to identify pediatric patients treated for complications of sinusitis at University Hospital (UH) from 1996 to 2004. Only patients age 18 or younger at the time of admission were included in this study. The following data were collected from hospital medical records: age, gender, past medical and social history, presenting symptoms, history of present illness, microbiology, surgical and medical intervention, and outcome. Twelve patients were identified that fit the criteria for this study. The mean age of these patients was 14.1 years, and 10 of our 12 patients were male (83.3%). The most common presenting complaints were fever, headache, altered mental status, orbital cellulitis, nasal symptoms, nausea and vomiting, and photophobia. In the week prior to admission for intracranial complications, nine patients were seen by a physician: five patients were seen in the ER and four by a primary care physician. Subdural empyema was the most commonly observed intracranial complication in this series. Microaerophilic and anaerobic organisms were most commonly identified in this series. Most sinus procedures consisted of endoscopic ethmoid and maxillary sinus drainage. There was a long-term morbidity rate of 16% and a mortality rate of 8%. Three conclusions may be drawn from this study. First, the morbidity and mortality of intracranial complications of sinusitis remain high in the pediatric inner-city population despite adequate access to medical care. Second, subdural empyema appears to arise in the setting of subacute rather than acute frontal sinusitis. Lastly, there may be an under-diagnosis and delay in treatment of patients with frontal sinusitis, resulting in subsequent intracranial complications.