Yezan Abderrahman, MD
Pediatric Critical Care Fellow
University of Iowa Hospital and Clinics
Iowa City, IA, United States
Disclosure information not submitted.
Aditya Badheka, MD, MS
Clinical Associate Professor, Pediatric Critical Care
University of Iowa Hospital and Clinics
Iowa City, Iowa, United States
Disclosure information not submitted.
Cody Tigges, DO
Clinical Associate Professor, Pediatric Critical Care
University of Iowa Hospitals and Clinics
Iowa City, Iowa, United States
Disclosure information not submitted.
Title: A Case of Pansinusitis Complicated by Pott’s Puffy Tumor and Subdural Empyema in a Pediatric Patient
Case Report Body:
Introduction: Extensive bacterial sinusitis can be complicated by abscess formation. One rare entity described in literature is Pott’s Puffy tumor where a subperiosteal abscess develops in the anterior wall of frontal sinus. Pott’s Puffy tumor can be associated with serious complications related to intracranial extension and septic embolization including meningitis, venous sinus thrombosis, and brain abscess formation.
Description: A 13-year-old male with history of failure to thrive and iron deficiency anemia presented with fever, rhinorrhea, nasal congestion, and worsening frontal headaches of two-week duration. Significant laboratory findings included elevated white blood cell count 35.3 * 103 cell/mm3 with neutrophilic predominance. Elevated erythrocyte sedimentation rate and C-Reactive Protein at 132 mm/hr and 8.7 mg/dl, respectively. CT scan of head revealed acute sinusitis of left maxillary sinus, bilateral ethmoid sinuses, and frontal sinus along with large subgaleal abscess around left orbit concerning for Pott’s Puffy tumor. Brain MRI revealed subdural empyema. He underwent incision and drainage of 12 cm* 4 cm external left subgaleal abscess over scalp area by otolaryngology and anterior orbitotomy to drain a left orbital abscess by ophthalmology. Orbital fluid grew streptococcus angiosus, and scalp fluid grew fusobacterium nucleatum. He also developed seeding to his lungs with multifocal pneumonia, bronchiectasis and associated pneumatocele formation likely secondary to septic embolization from his intracranial infectious process. Patient was started on parenteral ceftriaxone, metronidazole and vancomycin and subsequently switched to oral linezolid and intravenous meropenem. He improved significantly as he completed 6-week course of antibiotics. Following his admission and given his clinical picture he was worked up for both cystic fibrosis and primary immunodeficiency and both were non diagnostic.
Discussion: Pott’s Puffy tumor despite being rarely reported in the current era remains a serious complication of bacterial sinusitis with high mortality and morbidity. Associated intracranial complications have been reported more frequently in pediatric patients. Timely diagnosis and early intervention are crucial. Broad-spectrum antibiotics and surgery remain the cornerstones of management.