Pott puffy tumor: a rare case of secondary headache

Case presentation: F.L.A.R., 12 years-old, male, reporting severe frontal headache with fever and emesis for 7 days, with edema in the frontal cephalic and periorbital region, diagnosed as sinusitis and prescribed amoxicillin+clavulanate (A/C). Due to the persistence of symptoms on third day, he was admitted in hospital. On physical examination, the center of his forehead had a soft, tender, warm, swollen area that caused an obvious bulge. Facial ultrasound showed a frontal abscess. Skull computed tomography showed frontal subcutaneous abscess, epidural and subdural empyema, and associated local osteomyelitis. This finding confirmed the diagnosis of Pott puffy tumor. On the third day of hospitalization, he underwent a neurosurgical procedure to drain the empyema. Abscess culture with S.aureus. Used Ceftriaxone for 21 days, Clindamycin for 10 days. He was discharged from hospital on the 21st day with indication of domiciliary use of A/C for 10 days.

Discussion: The case is an important complaint of severe acute headache secondary to a less prevalent pathology. A Pott puffy tumor (PPT) is defined as swelling of the forehead, usually from the anterior extension of frontal sinusitis, and associated osteomyelitis of the frontal bone. It was first described by Sir Percival Pott as a complication of forehead trauma and after, in relation to sinusitis. When not treated promptly, osteomyelitis of the frontal bone and the resulting subperiosteal abscess gives rise to the characteristic PPT. It is a rare entity that is generally seen in older children. It can be associated with subdural empyema, epidural or brain abscess, and cortical veins. Intracranial involvement is possible, with or without direct erosion of the frontal bone. Treatment must contain broad-spectrum intravenous antibiotics and analgesics. A CT scan with contrast and MRI should be done to confirm the diagnosis and rule out intracranial complications. Surgical intervention may be necessary and neurosurgical consultation is always required in the case of intracranial involvement.

Final comments: Headache is one of the most frequent medical symptoms in outpatient clinics. The case reported is a typical presentation of a rare diagnosis and therefore not considered among the usual hypotheses. PPT should be among the likely diagnostic hypotheses of severe secondary headache. Prompt diagnosis and proper treatment will decrease the morbidity and mortality associated with this rare condition.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
18 September 2023