Keywords
Pott's puffy tumor - odontogenic - sinusitis
Introduction
First described by Sir Percival Pott in the middle of the 18th century, Pott's puffy
tumor (PPT) consists of osteomyelitis of the frontal bone with an associated subperiosteal
abscess.[1]
[2]
[3] Generally, it is seen as a sequela of frontal sinusitis and presents with forehead
swelling and pain. Adolescents are at the highest risk for PPT, likely due to increased
vascularity of the diploic circulation,[1] but patients of any age can be affected. This disease entity has become significantly
less common since antibiotic therapy became widely available.[3] Treatment of PPT usually requires a combination of antibiotic therapy and surgery.[1]
[3]
The recent literature has improved our understanding of odontogenic sinusitis and
we now understand that this disease process is much more common than previously thought.[4] Frontal sinus extension of odontogenic sinusitis occurs relatively frequently, but
PPT is remarkably rare.
Case Report
A 53-year-old male patient presented to the otolaryngology clinic with a 3-month history
of yellow nasal discharge, frontal headache, periorbital edema, and progressively
worsening midline forehead swelling ([Fig. 1]). He was initially evaluated by his primary care provider who obtained computed
tomography (CT) imaging and referred the patient to our institution for further evaluation.
He was also empirically prescribed an oral antihistamine and nasal steroid spray,
which failed to alleviate his frontal headaches. He had no history of recurrent or
chronic sinusitis, nasal obstruction, or disruptions in smell or taste, and denied
any history of local trauma or prior sinus surgery. His medical history consisted
of hypothyroidism, but otherwise, he was healthy without any signs of immunodeficiency.
He was prescribed a course of amoxicillin–clavulanate 875–125 mg twice daily, and
repeat imaging was obtained prior to surgical intervention.
Fig. 1 Preoperative image showing forehead swelling consistent with Pott's puffy tumor.
CT imaging revealed right-sided maxillary, ethmoid, and frontal sinus opacification
as well as evidence of PPT ([Figs. 2] and [3]). Thickened and sclerosed walls of the bilateral frontal, maxillary, and anterior
ethmoid cells were noted, denoting chronic sinus infection. Carious right maxillary
molars were also identified with periapical lucency indicating a likely endodontic
source of infection ([Fig. 4]).
Fig. 2 Sagittal computed tomography (CT) image showing evidence of sinus opacification and
Pott's puffy tumor.
Fig. 3 Coronal computed tomography (CT) image (left) and three-dimensional (3D) reconstruction
image (right) showing frontal sinus opacification and anterior wall erosion.
Fig. 4 Coronal computed tomography (CT) image (left) and sagittal CT image (right) showing
complete opacification of the right paranasal sinuses with periapical lucency of the
maxillary molars.
He subsequently underwent endoscopic sinus surgery using image-guided navigation.
Intraoperatively, copious pus was found in the right maxillary and ethmoid sinuses.
When attempting to access the frontal sinus, dense osteitic bone, secondary to chronic
inflammation, was encountered. This was subsequently drilled in a DRAF 2a procedure
to access the sinus. Again, a significant volume of purulent debris was encountered
and drained endoscopically. All involved sinuses were irrigated, cultures were obtained,
and steroid eluting stents were placed. Cultures showed evidence of polymicrobial
infection, including Streptococcus salivarius, Prevotella, and Rothia species. After discharge from the hospital, he completed a 6-week course of intravenous vancomycin
15 mg/kg every 12 hours and piperacillin/tazobactam 3.375 g every 8 hours.
He returned for 1-month, 4-month, and 7-month visits postoperatively, with the stents
being removed at his 1-month follow-up appointment. His symptoms of headache and drainage
had resolved, and the forehead swelling had significantly improved by the first visit.
Nasal endoscopy showed a patent frontal sinus with no purulent drainage. Between the
1-month and the 4-month visit, he underwent treatment for dental caries. Imaging at
the 7-month appointment showed no evidence of recurrence ([Fig. 5]). He was discharged from our clinic at this time having demonstrated lasting resolution
of symptoms and no evidence of persistent disease or obstruction on CT or endoscopy.
Fig. 5 Seven-month postoperative computed tomography (CT) imaging. Sagittal CT image (left)
and coronal CT image (right) showing resolution of PPT and improvement in paranasal
sinus disease.
Discussion
PPT is a rare disease process in adults. A 2015 review by Tatsumi et al stated that
only 54 adult cases had been reported in the Japanese and English literature.[1] Literature search found odontogenic PPT to be considerably less common with only
two cases linking PPT to dental disease.[2]
[3]
Chandy et al reported a case of PPT that arose following tooth extraction.[2] In this case, a 21-year-old male patient developed bacteremia, a lung abscess, PPT,
and an epidural abscess after undergoing tooth extraction. On presentation, he had
no evidence of dental disease, but the sinus disease was attributed to his recent
extraction and subsequent bacteremia. Geyton et al described a case in which a retained
tooth root served as the likely source of PPT in a 45-year-old male.[3] The case reported here is singular in terms of presentation of PPT resulting from
sinusitis due to routine carious dentition.
Often there are precipitating factors that result in the development of PPT. Adolescents
are the most frequently affected population, which is attributed to increased diploic
vein flow and maturing of the frontal sinuses.[1]
[2]
[5] The most common cause reported among adults is frontoethmoidal duct stenosis secondary
to recurrent sinusitis, trauma, or previous sinus surgery. Chronic rhinosinusitis
is a known risk factor for PPT, along with various other underlying diseases and patient
factors, including diabetes, chronic renal failure, aplastic anemia, and intranasal
cocaine or methamphetamine abuse.[1]
[5] In addition, sinus anomalies, such as Kuhn type IV cells, which obstruct the frontal
sinus ostium, may increase the risk of developing PPT.[5]
While the patient in our case denied any history of recurrent or chronic sinusitis,
we believe that his dental infection likely predisposed him to PPT. CT imaging showed
signs of sclerosed and thickened bone, indicating that the patient had chronic inflammation
within his paranasal sinuses. Additionally, osteitic bone was encountered during surgery.
He likely experienced occult or minimally symptomatic chronic sinusitis, exacerbated
by his odontogenic maxillary sinusitis, which spread to the frontal sinuses and progressed
to PPT. This patient had no other identifiable risk factors or sinus anomalies that
would result in increased susceptibility to PPT.
Odontogenic sinusitis is becoming increasingly recognized as a major source of sinusitis.[4] Multidisciplinary teams can be involved in the treatment of these patients. Prompt
referral of patients with odontogenic sinusitis to dentistry can decrease the morbidity
and potential complications from recurrent sinus infections. This is highlighted by
the delays in dental care in this case. Classically, unilateral, odontogenic sinusitis
can involve any sinus despite only the maxillary sinus being adjacent to the teeth.
Frontal sinusitis from an odontogenic origin is a well-known and reported entity.[4] However, from our literature search, PPT of odontogenic origin is exceptionally
rare and therefore noteworthy.
PPT can often be accompanied by intracranial complications. Singh et al found that
85% of patients with PPT had accompanying intracranial complications.[6] In these cases, swift diagnosis and treatment are paramount. This case is a reminder
that even when patients do not have a history of trauma or chronic sinusitis, but
present with symptoms of PPT, prompt imaging and intervention are necessary to mitigate
the risk for further morbidity as seen in these previous studies.
Conclusion
This unusual case of PTT highlights the morbidity that can occur from dental caries
and odontogenic sinusitis. Prompt CT imaging in patients reporting symptoms of frontal
sinusitis is important to exclude potential extrasinus complications, including PPT.
Multidisciplinary care, involving both dentistry and otolaryngology, is vital to provide
definitive management in these patients in the form of antibiotic therapy, endoscopic
sinus surgery, and dental treatment. Thorough dental examination should be performed
in patients presenting with sinusitis and clinicians should encourage patients to
undergo immediate dental treatment to prevent recurrences.
