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Nasal congestion, painful swelling over forehead in 10-year-old boy
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Carlos Martinez
Michael Cater
A 10-year-old boy presents with sudden pain and swelling over his forehead with severe headache over the last 24 hours. His history was positive for sustaining a head injury while skateboarding several days earlier, for which he was taken to the local ED for evaluation; a CT scan revealed frontal, ethmoid and left maxillary sinus opacification, with no fracture found.
Some additional history subsequently obtained revealed that the patient had been experiencing some intermittent fever, nausea with occasional vomiting, headache and congestion during the preceding 2 weeks prior to presenting with the chief complaint. At that time, the patient was sent home with a prescription for cefdinir to treat the sinusitis, which he felt helped his symptoms some prior to the onset of the sudden pain and swelling noted above.
Figure 1. 10-year-old boy presents with sudden pain and swelling over his forehead.
Source: Brien JH
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Figure 2. 10-year-old boy presents with sudden pain and swelling over his forehead.
Source: Brien JH
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Figure 3. MRI of swelling soft tissue with subperiosteal abscess.
Source: Brien JH
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Figure 4. MRI of swelling soft tissue with subperiosteal abscess.
Source: Brien JH
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Examination revealed a fairly healthy-appearing 10-year-old boy with normal vital signs, who had some nasal congestion and significant, painful swelling over his forehead, as shown in Figures 1 and 2. The patient was subsequently sent to the children’s hospital ED for further evaluation and admission for therapy. An MRI with contrast is shown in Figure 3 (T2 axial) and Figure 4 (T2 coronal post-contrast).
Case Discussion
This patient has a classic case of Pott puffy tumor (B), as originally described by Sir Percivall Pott in 1760. This condition is classically the consequence of severe frontal sinusitis that has spread beyond the sinus space to involve the overlying frontal bone — with the resultant swelling of the soft tissue (the puffy tumor) with a subperiosteal abscess — and occasionally can extend intracranially (Figures 3 and 4).
Figure 5. Left frontal sinus trephination with drain placement.
Source: Brien JH
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Figure 6. Similar case from November 2001 issue.
Source: Brien JH
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This condition was fairly common in the pre-antibiotic era, and typically occurred in those with underlying sinus disease and/or injury. The cause is usually driven by gram-positive cocci, such as Staphylococcus aureus or streptococci, and frequently has multiple other “sinus” organisms in the mix as well, including anaerobic bacteria. Best management almost always involves surgical drainage with prolonged antimicrobial therapy that should ideally be culture-directed. The patient underwent surgical drainage by intranasal endoscopic surgery and left frontal sinus trephination with drain placement (Figure 5). The patient subsequently grew Streptococcus intermedius, one of the species of the Streptococcus anginosus group, and an increasingly common cause of complicated sinus and central nervous system infections. He was treated with ceftriaxone plus metronidazole (presuming other organisms, mostly anaerobes, may have likely been present as well) for a total of 6 weeks with complete recovery.
Figure 7. Necrotic frontal bone.
Source: Brien JH
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Regarding the other choices, a significant head injury should be obvious from the history and should have been seen on either the CT or MRI imaging. The choices of frontal or left maxillary sinusitis are technically correct in that he did have radiographic evidence of these conditions, but the most correct answer (as often seen in board exam questions) was Pott puffy tumor.
For those interested, another patient with Pott puffy tumor was featured in this column in the November 2001 issue (Figure 6). In that case, the patient had undergone a surgical procedure several weeks earlier, which apparently set the stage for the frontal sinus infection. Lewis R. Hutchinson, MD, one of our pediatric otolaryngologists, provided Figure 7, which shows the appearance of necrotic frontal bone in yet a different patient with Pott puffy tumor, to demonstrate what is going on beneath the surface.
Thanks (again) to Michael Cater, MD, and his colleague, Carlos Martinez, MD, for their contribution of this case. They are both staff pediatricians at the Children’s Hospital of Orange County, an outstanding children’s healthcare facility in Southern California, where I was very fortunate to be a visiting professor in 2015. Dr. Cater has contributed numerous cases over the years for teaching purposes, most of which have appeared in this column.
- For more information:
- James H. Brien, DO, is with the department of infectious diseases at McLane Children’s Hospital, Baylor Scott & White Health, Texas A&M College of Medicine in Temple, Texas. He also is a member of the Infectious Diseases in Children Editorial Board. Brien can be reached at: jhbrien@aol.com.
Disclosure: Brien reports no relevant financial disclosures.