Pott Puffy Tumor

What is Pott Puffy Tumor?

The Pott puffy tumor (PPT) is a condition where the forehead swells as a result of an infection in the frontal bone of the skull combined with an abscess, which is a pocket of pus. This condition was first identified by a London surgeon named Sir Percival Pott in 1768. The term “tumor” in this context doesn’t mean cancer; it’s used to refer to the noticeable swelling in the forehead.

Originally, this condition was believed to be caused by a direct injury to the forehead. However, we now understand it typically arises as a complication from an infection in the frontal sinuses. This is most usually seen in young adolescents. Its symptoms include a precisely defined, sensitive swelling on the forehead along with other signs like fever, headache, a runny nose or increased pressure within the skull. It’s essential to diagnose and treat this condition early for the best patient outcomes.

What Causes Pott Puffy Tumor?

There are several things that can cause PPT, a serious complication that is rare but can occur if sinusitis or a head injury is not properly treated. PPT stands for Pott’s Puffy Tumor, which is not actually a tumor but an area of swelling in the forehead due to an infection.

Sinusitis, an inflammation or swelling of the tissue lining the sinuses, is the most common cause of PPT. Sinusitis is quite common, affecting 1 in 8 people in the United States. Most people get better without any problems, but a small percentage of people (0.5% to 2%) develop bacterial sinusitis. Among these, 80% get better without needing antibiotics. However, if bacterial sinusitis is left untreated, it occasionally leads to complications like PPT.

Head injuries, especially ones to the forehead, are the second most common cause of PPT. After a wound is inflicted, the resulting infection or contamination can eventually lead to PPT. It’s important to note that PPT doesn’t develop through secondary septic thrombophlebitis, which is a blood clot causing inflammation in the vein.

Other less common causes of PPT include cranial or forehead surgery, dental infections, cocaine abuse, injuries from wrestling, and insect bites.

There are also certain risk factors that can make a person more likely to develop PPT, such as diabetes, chronic kidney failure, aplastic anemia, and other conditions that weaken the immune system.

In most cases, PPT is caused by an infection from multiple types of bacteria. The most likely culprits are non-enterococci streptococci, anaerobic oral bacteria, and staphylococci. Less commonly, bacteria such as Fusobacterium, H. Influenza, Enterococcus, Pseudomonas, Escherichia Coli, Pasteurella multocida, Proteus, and Bacteroides can be involved.

Risk Factors and Frequency for Pott Puffy Tumor

The Pott puffy tumor is a rare condition that has become even less common due to the use of modern, broad-spectrum antibiotics. Although rare now, early detection and treatment significantly improve the outcome. The Pott puffy tumor can affect all ages, but it is more frequently found in children and young teenagers. The condition is also more likely in people with weakened immune systems. That said, it is very seldom seen in adults with healthy immune systems.

Infection can occur in children because the process of the frontal and ethmoid sinus filling with air begins in early childhood. However, this process varies in duration and may not complete until one is 15 to 18 years old.

Signs and Symptoms of Pott Puffy Tumor

The Pott Puffy Tumor (PPT) is a condition most often diagnosed in individuals aged 6 to 15, but can occur at any age. The typical symptoms include a soft, tender swelling on the forehead that may feel like dough. This swelling is often red and is usually accompanied by a fever. This combination of symptoms – forehead swelling, headache, fever, and a runny nose or discharge, is common in PPT.

Sometimes, a fever may not be present. Other symptoms that may occur include swelling around the eyes, nausea, vomiting, skin sores that are open and seeping, meningitis or inflammation of the brain.

In children, symptoms may be non-specific and can vary according to the severity of the infection. Usually, the symptoms include a headache, runny nose, and fever. A soft, tender swelling on the forehead should raise suspicions of PPT.

If increased pressure within the skull is suspected due to symptoms such as nausea, vomiting, sensitivity to light, weaknesses in the nerves of the skull, seizures, changes in mental state, lethargy, or a reduced level of consciousness, it is crucial to seek urgent medical help. Researchers recommend immediate diagnosis, scanning, consultation with neurosurgeons or ear, nose and throat specialists, and treatment.

Testing for Pott Puffy Tumor

If your doctor suspects you may have a Pott puffy tumor, they will quickly arrange an imaging test. This type of tumor can be detected using either a contrast-enhanced head CT scan or a brain MRI scan. Both methods can confirm the presence of the tumor and reveal any complications inside the skull. Early diagnosis and treatment can significantly improve your outlook, so these tests need to be done urgently.

A head CT scan with contrast is often done first because it’s fast and confirms the diagnosis. This kind of scan can reveal inflammation in the front part of the sinuses (frontal sinusitis), bone erosion, accumulation of fluid under the membrane covering the bone (subperiosteal collection), and the spread of the disease inside the skull. This method gives the best images where air meets bone or soft tissue, but it does involve some radiation. Because of this, it’s typically not recommended for follow-up imaging due to an increased risk of developing cancer from repeated exposure to radiation.

A contrast-enhanced brain MRI is often preferred, if possible and available. It can provide a better understanding of any complications inside the skull and show how far infection has spread. Additionally, it can detect blood clotting in the brain’s drainage system (dural sinus thrombosis) and also helps in detecting abscess due to its better soft-tissue resolution and excellent evaluation of brain and subdural space. However, it’s less effective at showing bone destruction. This type of scan is usually recommended for follow-up testing after surgery because it doesn’t use radiation. But in some centers, getting an MRI can be difficult and may lead to delays in diagnosis and treatment.

Bone scans are another possible tool, although less commonly used. These scans are more sensitive than CT scans for detecting early infections in the bone (osteomyelitis), but they are not as useful if you already have clinical signs of the condition.

Along with imaging, your doctor may also suggest a laboratory workup. This could include a complete blood count, comprehensive metabolic panel, erythrocyte sedimentation rate (which indicates inflammation in the body), and C-reactive protein (another sign of inflammation).

Treatment Options for Pott Puffy Tumor

Pott puffy tumor is a medical condition that requires immediate diagnosis and treatment to prevent complications and improve patient outcomes. Current evidence suggests the best approach to managing this condition is a mix of medication and surgery. Treatment typically involves using strong antibiotics to control the infection, along with surgical procedures to drain any abscesses, remove affected tissue, and aid the flow of mucus from the sinuses.

Patients suspected of having Pott puffy tumor are typically admitted to the hospital right away. They are then given a range of treatments, such as strong intravenous (or IV, directly into the bloodstream) antibiotics, IV fluids to prevent dehydration, painkillers, and they will undergo medical imaging (like an MRI or CT scan) to confirm the diagnosis. If the condition is indeed Pott puffy tumor, experts in ear, nose, and throat care and brain surgery are brought on board to help manage the case.

The IV antibiotics need to start immediately when Pott puffy tumor is suspected. They help combat the most common types of bacterial infections associated with this condition. It’s crucial to select antibiotics capable of crossing the blood-brain barrier to treat any infection affecting the brain. Medications typically include classes such as penicillins, vancomycin, 3rd generation cephalosporins, and metronidazole. Once results from bacterial cultures are available, these broad-spectrum antibiotics may be swapped for more specific ones. Treatment durations can vary but often require several weeks of IV antibiotics after surgery. In some cases, fluid collections may be treated with IV antibiotics, but a biopsy is strongly recommended to identify the bacteria and guide medication choices.

Meanwhile, surgical options include conventional open surgery or minimally invasive techniques (like endoscopic intranasal frontal sinusotomy). The goal of surgery is to drain the sinus and remove infected bone tissue- both crucial steps for successful treatment. Traditionally, open surgery was the norm as it allows better visibility of the target area, but it might leave a significant cosmetic deformity. Nowadays, endoscopic techniques are more popular. This type of surgery has fewer risks and complications, quicker recovery times, and avoids external scarring. The appropriate surgical procedure will depend on individual patient factors, such as the location and extent of the disease.

Surgical options include: Craniotomy, a procedure where a section of the skull is removed for direct access to the frontal sinus for radical cleansing of the infection and removal of affected bone or abscess. It carries a high risk of cosmetic deformity due to surgical scars and other complications. Trephination, where a hole is drilled into the skull for abscess draining. Frontal sinus obliteration, which involves removing all the infected sinus tissue to prevent future infections. Lastly, minimally invasive endoscopic frontal sinusotomy, a procedure that drains the sinus and removes infected tissue.

What else can Pott Puffy Tumor be?

When diagnosing Pott puffy tumor, a variety of other conditions could potentially be causing the symptoms. These include but are not limited to:

• Simple acute sinusitis (a quick onset sinus infection)
• Chronic sinusitis (long term sinus infection)
• Benign/malignant neoplasms (noncancerous or cancerous tumors)
• Soft tissue infection
• Skin infection
• Infected hematoma of frontal area (infectious pooling of blood in the forehead)
• Inflammation from trauma
• Cephalohematoma (pooling of blood under the skin of the head, often from birth trauma)
• Foreign body causing purulent rhinorrhea (something stuck causing a pus-filled runny nose)
• Meningitis (infection of the membrane covering the brain)
• Encephalitis (inflamed brain)
• Brain abscess (pus-filled pocket in the brain)
• Seizures

Doctors must consider these potential diagnoses when examining a patient with symptoms similar to Pott puffy tumor.

What to expect with Pott Puffy Tumor

The health outcomes, death rates, and future outlook for Pott puffy tumor (PPT), a rare condition characterized by a swelling on the forehead, largely depend on how early and effectively it is treated. If this condition is left untreated or not treated early enough, the patient may face severe complications, including brain-related issues, which can worsen the future outlook.

Furthermore, the longer the Pott puffy tumor is left without treatment, the more likely it is for the patient to have a worse health outlook in the future. Therefore, early and effective treatment is crucial to improving prognosis and reducing the risks associated with this condition.

Possible Complications When Diagnosed with Pott Puffy Tumor

Intracranial complications are the most frequent complications in patients with Pott Puffy Tumor, showing up in about 60-85% of cases. Such complications could be due to the infection spreading into the brain or an inflammatory condition in the veins caused by the infection. If treatment is delayed after diagnosis, these complications become more common and severe.

The complications commonly observed include:

• A condition where pus collects between the brain and its outermost cover (Subdural/epidural empyema)
• Inflammation of brain membranes (Meningitis/encephalitis)
• Formation of an abscess in the front part of the brain (Frontal lobe abscess)
• Formation of pus-filled pockets in different parts of the brain (Subdural/epidural/intraparenchymal abscess)
• Formation of clots in a major vein in the skull (Cavernous sinus thrombosis)
• Brain vein thrombosis
• Dural venous sinus thrombosis
• Inflammation of the space between the brain and its covering (Subarachnoid inflammation)

Eye infection (Orbital cellulitis) can occur if the lower wall of the frontal sinus gets infected. In such cases, seeing an eye doctor becomes necessary. The same approach is necessary if there’s an abscess under the eye socket due to the lower sinus wall’s involvement.

Surgery-related complications depend on whether an endoscopic or open approach is taken. In endoscopic approaches, possible risks include:

• Vision loss
• Leakage of the fluid that surrounds the brain and spinal cord (CSF leak)
• Seizures
• Infections coming back
• Blocked nose
• Nasal scarring
• Bleeding

For open approaches, the same complications are possible. But, other problems might occur, such as upper eyelid or forehead paralysis, numbness in the forehead and scalp, and more noticeable cosmetic changes due to external scarring.

Preventing Pott Puffy Tumor

The Pott puffy tumor is a rare condition that can be deadly if not treated. It’s important for parents to keep an eye on their child’s signs and symptoms when they have a sinus infection. If your child has recurring sinus infections along with symptoms like headaches, fever, a runny nose with pus, or swelling on the forehead, it’s necessary to take them to the emergency room straight away. Quickly identifying and treating the Pott puffy tumor is vital in order to achieve the best possible health outcome.