Forehead swelling in a 10-year-old male: A case report

Case data
A 10-year-old boy presented to a regional hospital emergency department with forehead swelling 2 weeks after he had experienced 4 days of upper respiratory tract infection with symptoms of high fever, periorbital swelling, and frontal headaches. A CT scan of his sinuses revealed partial opacification of bilateral ethmoid, maxillary, and sphenoid sinuses (Figure 1A). A diagnosis of acute bacterial rhinosinusitis was made, and he was treated with intravenous cefuroxime for 2 days followed by oral cefuroxime for 9 days. In addition to antibiotics, he was prescribed the nasal decongestant xylometazaline. However, the patient could not tolerate the decongestant and did not use it. 

With completion of the antibiotic therapy, the patient’s pain resolved and the forehead swelling decreased slightly. However, 2 days after stopping the antibiotics, the forehead swelling increased to the point where the patient was unable to put on a ski helmet, prompting a return to the emergency department. On physical examination he was found to have periorbital edema and fluctuant erythematous forehead swelling. A CT scan of his sinuses was repeated and showed progression to complete opacification of both frontal sinuses, but decreased opacification within the rest of the paranasal cavities. Importantly, the opacification within the frontal sinuses now appeared to erode through the anterior table of the frontal bone, continuing anteriorly as a 1.8 cm by 5.0 cm by 8.0 cm collection of fluid (Figure1B). A diagnosis of Pott’s puffy tumor was made: acute bacterial rhinosinusitis complicated by osteomyelitis of the frontal bone. 

The patient was started on intravenous ceftriaxone and clindamycin and transferred to BC Children’s Hospital for definitive surgical treatment. Shortly after admission (Figure 2), he was taken to the operating room, where the nasal cavity was decongested with xylometazaline. Endoscopic examination revealed purulent fluid in the right middle meatus, which was suggestive of a draining frontal sinus. A 1-cm horizontal incision just inferior to the medial aspect of the right eyebrow was made and a fine hemostat was used to enter the abscess cavity bluntly (Figure 3A). A copious amount of purulent fluid was expressed and gentle lavage with normal saline was performed (Figure 3B). A Penrose drain was inserted through the wound and sutured in place. Specimens were taken for culturing to identify aerobic and anaerobic bacteria.

The patient improved swiftly in the postoperative period and saw a rapid decrease in facial swelling over 2 days (Figure 4). He was treated with nasal xylometazaline for only 72 hours (longer treatment might have resulted in rhinitis medicamentosa) and with normal saline nasal washes and nasal steroid spray for several weeks. He continued on intravenous ceftriaxone and clindamycin antibiotics for 6 weeks, appropriate given the growth of penicillin-susceptible Streptococcus intermedius in the cultured specimens of abscess fluid. He experienced a complete resolution of symptoms, and no recurrence of sinusitis was found at follow-up 8 months later. 

Discussion
Acute bacterial rhinosinusitis is common in both adults and children. Estimates suggest it is diagnosed annually in 12% of adults[1] and is present in 6% to 7% of children seeking care for respiratory symptoms.[2] The 2011 Canadian clinical practice guidelines for acute and chronic rhinosinusitis define acute bacterial rhinosinusitis as the presence of nasal obstruction or nasal purulence/discolored postnasal discharge and either facial pain/pressure/fullness or hyposmia/anosmia for more than 7 days.[3] It is important to note that in a pediatric population the symptoms of acute bacterial rhinosinusitis are indistinguishable from adenoiditis.[4] Adenoiditis is the sole diagnosis in up to 10% of children who show symptoms and signs consistent with acute bacterial rhinosinusitis. The use of nasal endoscopy can help distinguish between acute bacterial rhinosinusitis and adenoiditis.[5]

Complications of acute bacterial rhinosinusitis can be classified as intracranial or extracranial. Intracranial complications include meningitis, intracranial abscess, and cavernous sinus thrombosis. Extracranial complications include periorbital cellulitis, orbital abscess, and Pott’s puffy tumor. With the advent of antibiotics these complications have become relatively rare. 

Pott’s puffy tumor presents as localized swelling over the forehead and is defined as osteomyelitis of the frontal bone with associated subperiosteal abscess.[6] Osteomyelitis is thought to be caused by infection of the frontal, ethmoid, and, more rarely, the maxillary sinuses secondary to obstruction of their common drainage pathway. Other reported causes of Pott’s puffy tumor include trauma, cocaine abuse, dental infections, carcinomas, insect bites, and acupuncture treatments.[7]

Pott’s puffy tumor is known to be most common in adolescent males. During adolescence the frontal sinuses reach adult size and there is peak vascularity in the valveless diploic veins of the skull. These two factors may contribute to the relatively high occurrence of Pott’s puffy tumor in adolescence,[7] although they do not explain the greater prevalence of the disease in males. 

The natural history of Pott’s puffy tumor in children is well documented. Records from John Hopkins Hospital show a mortality rate of 60% between 1930 and 1937, before the advent of antibiotics, largely due to uncontrolled intracranial spread of the infection. With the use of sulfa drugs starting in 1938, the mortality rate dropped to 33% by 1944. With the use of penicillin starting in 1952, the mortality rate dropped to 3.7% by 1964.[8] 

Prompt surgical drainage of the abscess and 6 weeks of intravenous antibiotic therapy are key to the successful treatment of Pott’s puffy tumor,[6] although the evidence supporting this treatment is limited to a small case series. The extent of surgical treatment remains controversial and must be decided on a case-by-case basis.[6] There are several encouraging case series that support transnasal endoscopic drainage of frontal abscess.[9,10] In the case described here, a decision was made not to perform endoscopic sinus surgery because the examination of the nasal cavity showed purulence draining into the nasal cavity, suggesting that the frontal sinus recess was at least partially open. 

It is unclear why the patient in this case failed to respond to initial appropriate antibiotic treatment and progressed to develop osteomyelitis of the frontal bone. Possibly the patient’s inability to tolerate the nasal decongestant prescribed when acute bacterial rhinosinusitis was diagnosed played a part, since adjunct therapies, including nasal decongestants (e.g., xylometazailine spray), nasal steroids (e.g., mometazone spray), and nasal saline washes, are thought to relieve the obstruction of narrowed sinus ostia and contribute to the mechanical clearance of the infected fluid trapped in the sinuses. 

The use of adjunct therapies for acute bacterial rhinosinusitis is controversial because of a lack of appropriately designed studies investigating their effectiveness.[11] The 2013 American Academy of Pediatrics guideline for acute bacterial rhinosinusitis makes no recommendation on the use of adjunct therapies,[2] while the 2015 American Academy of Otolaryngology guideline recommends discussing adjunct measures with patients as an option for symptomatic relief of acute bacterial rhinosinusitis.[12] By contrast, the 2011 Canadian guideline for acute and chronic rhinosinusitis recommends the use of intranasal corticosteroid for acute bacterial rhinosinusitis.[3] 

While adjunct measures for complicated acute bacterial rhinosinusitis have not been studied adequately, a case note and literature review indicates the majority of clinicians recommend them[13] and consider such low-risk interventions an acceptable way to provide symptom relief[3] and assist with mechanical clearance of the sinus blockage. Thus, until further evidence is available, the authors would recommend the use of adjunct measures.

Summary
A classic example of Pott’s puffy tumor is seen in the case of a 10-year-old male who presented with forehead swelling after an upper respiratory tract infection and acute bacterial rhinosinusitis. Despite treatment with appropriate antibiotic therapy he progressed to develop osteomyelitis of the frontal bone associated with a subperiosteal abscess. The patient improved rapidly after surgical drainage, intravenous administration of broad-spectrum antibiotics, and adjunct treatment consisting of a nasal decongestant, nasal steroid spray, and saline irrigation. The lack of adjunct treatment for acute bacterial rhinosinusitis may explain why the patient failed to respond to the initial course of antibiotic therapy. While the use of adjunct measures is controversial, we would encourage clinicians to consider such treatment for patients with acute bacterial rhinosinusitis, especially when patients show early signs of complications. 

Competing interests
None declared. 

This article has been peer reviewed.

At the time this case presented, Dr Butskiy was a PGY-3 resident and Dr Remillard was a PGY-5 resident in the Division of Otolaryngology – Head and Neck Surgery at the University of British Columbia. Dr Kozak is head of the Division of Pediatric Otolaryngology – Head and Neck Surgery at BC Children’s Hospital and a clinical professor in the Department of Surgery at the University of British Columbia.