Pott’s puffy tumour
• In the 18th century Percival Pott described the case of a patient with a pericranial abscess related to trauma. • The area, he noted, was ‘swollen and puffy’.
• The term pott’s puffy tumour describe a subperiosteal cellulitis or abscess of the frontal bone associated with frontal osteomyelitis.
• Anterior spread of acute frontal sinusitis through outer table of skull may cause a boggy subperiosteal abscess and osteomyelitis.
presentation :
• headache, • swelling • a discharging frontal fistula
Route of infection:
• The infection can spread posteriorly giving rise to intracranial sepsis either by erosion of the posterior table or more likely by septic thrombophlebitis via the diploic vein.
Management
• requires drainage of pus from the frontal sinuses, achieved either endoscopically or conventionally through a frontal sinus trephination via an incision in the superomedial aspect of the orbit.
• Prolonged antibiotic therapy, ideally culture-directed, for 6-8 weeks covering both aerobic and anaerobic organisms is recommended.
• Once the acute phase has subsided the patient should be re-evaluated to determine if a frontal sinus drainage procedure is required for long-term management. This can be undertaken endoscopically or externally through an osteoplastic frontal flap, or in combination . However, as these infections rarely recur, in general, patients can be reassured this an unlikely occurrence.
• A limited subperiosteal abscess may be drained through a Lynch Howarth brow incision. However, this does not allow adequate inspection of the frontal bone to assess for necrotic bone. An alternative is to perform a spectacle incision providing good exposure to the frontal sinus but resulting in a scar, which may not be acceptable cosmeti- cally.
• A bicoronal scalp incision and flap provides excellent access to assess the whole frontal sinus enabling removal of diseased bone.
• Associated intracranial complications necessitate prompt neurosurgical intervention. This is typically performed through a bifrontal craniotomy enabling drainage of intracranial pus and removal of necrotic bone.Complete removal of the posteric frontal sinus cranialization.
Extensive osteomyelitis ofthe anterior table may necessitate a Riedel’s procedure with removal of the anterior wall and floor of the frontal sinus allowing the forehead skin to collapse onto the posterior table. Whilst this causes a significant cosmetic a trauma.