1. To describe the clinical epidemiology, microbiology

BACKGROUND: Pott’s Puffy Tumor (PPT), an entity of subperiosteal abscess and osteomyelitis of the
frontal bone first described by Sir Percival Pott in 1760, occurs as a severe complication of chronic
pansinusitis and is associated with intracranial extension. Clinicians need to be aware of its
manifestations in order to appropriately treat their patients. The objective of this study was to describe
the epidemiology, clinical manifestations, treatment regimens, outcome and microbiology of children with
PPT.
METHODS: Retrospective chart review of patients (pts) hospitalized from 1995-2011 at Children’s
Memorial Hospital, a 273 bed free standing children’s hospital in Chicago, with ICD-9 discharge
diagnoses of PPT, sinusitis with complications, osteomyelitis/ abscess/cellulitis of face/skull, or
intracranial abscess/infection.
RESULTS: 24 cases of PPT were identified; 18 of the cases (75%) occurred in the last 5 years of the
study. The median age was 13.7 years (y) (mean 13 y, range 3.3 to 15.8 y); 87.5% were male (M).
41.7% were Black, 33.3% Caucasian, 12.5% Hispanic, 4.2% Asian, and 8.3% unspecified. 9 pts (37.5%)
received antibiotics (abx) within the prior month for presumed sinusitis. The most common presenting
symptoms included: headache (87.5%), forehead swelling and tenderness (87.5%), fever (75%),
periorbital swelling (41.7%), purulent nasal drainage (29%), and mental status changes (25%). Duration
of symptoms ranged from 2 days (d) to 6 months (mos). Median length of hospital stay was 8 d (mean
11.3 d, range 4-49 d). 23/24 (95.8%) required surgical intervention; 23/24 (95.8%) had intracranial
extension. Intracranial findings included: epidural abscess (91.3%), subdural empyema (30.4%), and
subgaleal abscess (13%). Cultures were positive in 75% of the cases; the majority of the infections were
polymicrobial. Organisms isolated included viridians Streptococci, Group C streptococci, Group F
streptococci, oral anaerobes, and Staphylococcal species. Ceftriaxone, ampicillin/sulbactam and
clindamycin alone or in combination were the most common agents used for therapy. Mean duration of
therapy was 6 weeks (range 5 to 24 wks). All patients recovered from their infection; 3 required
admission to a rehab facility.
CONCLUSIONS: PPT seems to be occurring more frequently and is associated with intracranial
extension in almost all cases. There is a clear M predominance especially in Black and Caucasian
adolescents in association with sinusitis. Disease is polymicrobial in majority of cases. Treatment
requires a combination of prolonged abx therapy and surgical drainage.
1. Retrospective chart review of patients (pts) hospitalized from 1995-2011 at Children’s Memorial Hospital (now Ann & Robert H. Lurie Children’s Hospital of Chicago), a 288 bed free standing
children’s hospital in Chicago, IL with ICD-9 discharge diagnoses of PPT, sinusitis with complications, osteomyelitis/abscess/cellulitis of face/skull, or intracranial abscess/infection.
2. Inclusion criteria included one or more of the following: documentation of diagnosis of Pott’s Puffy Tumor, history of facial/forehead swelling on admission, radiographic findings of extracranial
soft tissue swelling or abscess of the frontal bone, radiographic findings of osteomyelitis of the frontal bone, or frontal bone/facial tenderness and edema on physical examination.
3. Patients were excluded from analysis if they had intracranial hardware or an infection related to a recent cranial/facial surgical procedure (within last 1 month).
4. Information on patient demographics, underlying conditions, presenting signs and symptoms and duration, prior antibiotic therapy, radiographic studies, surgical intervention, microbiology,
length of hospitalization, antibiotic treatment regimen and duration, and clinical outcome was obtained.
TABLE 5 and TABLE 6 show the antibiotics that were used for
treatment in these pts. Ceftriaxone, ampicillin/sulbactam, and
clindamycin alone or in combination were the most common
agents used for therapy. The median duration of therapy was 6
weeks (wks) (mean 8.33 wks, range 5 to 24 wks). All pts
recovered from their infections although the severity of the
infections seem to be worse in those pts admitted from 20072011. Ten pts required antiepileptic medication upon hospital
discharge (7 were hospitalized in the 2007-2011 period) and 3 pts
were discharged to rehabilitation facilities (all diagnosed between
2007-2011). By the 6-8 wks follow up appointment, all pts except
2 (both diagnosed between 2007-2011) were noted to be without
any neurologic sequelae or further signs of infection. Of the pts
with persistent sequelae, one had a left hemiparesis,
tracheostomy, and was G-tube dependent and the other had a
right hemiparesis and global aphasia. There were no deaths in
this series of pts.
•
Monotherapy
─
─
─
─
Ampicillin/sulbactam (Unasyn) IV x 6 weeks (5)
Clindamycin IV x 6 weeks (1)
Ceftriaxone IV x 6 weeks (1)
Cefprozil PO x 6 weeks (1)
Combination Therapy
─ Ceftriaxone IV + Flagyl PO
Twenty four cases of PPT were identified during the study period; 18 of the cases (75%) occurred during the last 5
years of the study (2007 through 2011) as shown in FIGURE 1. The median age of the pts was 13.7 years (yrs) (mean
13 yrs, range 3.3 to 15.8 yrs); 87% (n=21) were male, 41.7% were Black, 33.3% Caucasian, 12.5% Hispanic, 4.2%
Asian, and 8.3% unspecified race. Two patients had underlying conditions – one with HIV and the other with Marfan
syndrome. TABLE 1 shows the presenting signs and symptoms of the pts. The most common presenting symptoms
included: headache (87.5%), forehead swelling and tenderness (87.5%), fever (75%), periorbital swelling (41.7%),
purulent nasal drainage (70% of pts with URI symptoms), and mental status changes (25%). The duration of symptoms
ranged from 2 days (d) to 6 months (mos). Ten pts (41.7%) received one or more courses of antibiotics (abx) within the
prior month for presumed sinusitis. Seven pts were on abx at the time of presentation (duration ranged from 2 d to 2
weeks). The most common antibiotics taken were: amoxicillin, azithromycin, cefadroxil, cefdinir, and cefuroxime axetil.
•
•
•
Table 1. Presenting Signs and Symptoms
Symptom
Number (%)
Duration
Forehead Swelling
21 (87.5%)
1d-6 months
Headache
21 (87.5%)
2d-6 months
18 (75%)
2d-2 weeks
Periorbital Swelling (intermittent)
10 (41.67%)
2-20 d
URI symptoms
Cough
Congestion
Purulent nasal drainage
10 (41.67%)
4 (40%)
5 (50%)
7 (70%)
2d-2 months
Fever
6 (25%)
5 (83.33%)
4 (66.67%)
•
•
•
Diagnosis
Sinus involvement
Frontal
Number of Patients
24 (100%)
22 (91.67%)
Ethmoid
23 (95.83%)
Sphenoid
9 (37.50%)
Maxillary
22 (91.67%)
Pan-Sinus Disease
21 (87.50%)
Table 3. Complications and Associated Intracranial Disease
Diagnosis
Number
Orbital Cellulitis/ Abscess
4 (16.67%)
Bacteremia
4 (16.67%)
Intracranial Complications
23 (95.83%)
Subdural Empyema
7 (30.43%)
Epidural Abscess
21 (91.30%)
Subgaleal Abscess
3 (13.04%)
Intraparenchymal Abscess
1 (4.35%)
Venous Sinus Thrombosis
2 (8.70%)
Meningitis
2 (8.70%)
TABLE 2 shows the sinus involvement that was
seen in these pts. Pan-sinus disease was seen in
87.5% of the patients with the ethmoid (95.83%),
frontal (91.67%) and maxillary (91.67%) sinuses
being the most commonly involved. TABLE 3
shows the complications and associated intracranial
disease in the pts. Some pts demonstrated more
than 1 complication. 23/24 (95.8%) of the pts had
intracranial extension of their infection. Intracranial
findings included: epidural abscess (91.3%),
subdural empyema (30.4%), and subgaleal abscess
(13%). The median length of hospital stay was 9 d
(mean 11.25 d, range 4 to 49 d). 23/24 pts (95.8%)
required surgical intervention; 23 required sinus
drainage and 16 (70%) also required neurosurgical
involvement for craniotomy or burr hole drainage.
Organisms
•
•
•
•
Cultures results were available for 21 of
the 24 patients (3 pts did not have
cultures obtained)
─ 6/21 had negative cultures
9/15 pts with positive cultures had
polymicrobial infections
3 had cultures with only viridans
streptococci
Only 1 S. aureus isolate – NOT MRSA
16 weeks – 6 weeks Ceftriaxone + Flagyl + 10 weeks Levaquin
7 weeks – 6 weeks Ceftriaxone + Flagyl + 1 week Levaquin
5 weeks – 4 weeks Ceftriaxone + Flagyl + 1 week Levaquin
─ Ceftriaxone IV + Flagyl PO followed by Cefuroxime PO (1)
•
4 months Ceftriaxone + Flagyl + 2 months Cefuroxime
─ Ceftriaxone IV + Clindamycin IV x 6 weeks (1)
─ Oxacillin IV + Flagyl PO x 6 weeks followed by PO clindamycin x 4 months (1)
1d
2d
2.
Table 4. Microbiology
Table 2. Sinus Disease
6 weeks (3)
8 weeks (6)
13 weeks (1)
─ Ceftriaxone IV + Flagyl PO followed by Levafloxacin PO (3)
1.
1. To describe the clinical epidemiology, microbiology, treatment regimens and clinical outcome of
children with Pott’s Puffy Tumor at our institution.
2. To determine if the incidence of disease is increasing and if MRSA has become a more prevalent
cause of this infection.
•
Table 6. Antibiotic Treatment
Mental Status Changes
Seizures
Depressed status
Pott’s puffy tumor is a subperiosteal abscess and osteomyelitis of the
frontal bone that appears as a localized, tender, fluctuant, boggy
(“puffy”) swelling of the overlying region of the forehead. It was first
described by Sir Percival Pott (1714-1788), a surgeon at St.
Bartholomew’s Hospital in London, in Observations on the Nature and
Consequences of Wounds and Contusions of the Head, Fractures of
the Skull, Concussions of the Brain, published in 1760. It occurs as a
severe complication of chronic pansinusitis and is associated with a
high risk of intracranial abscess, meningitis and venous sinus
thrombosis. For optimal patient outcome, management requires early
diagnosis and aggressive medical and surgical treatment. Although
PPT is a relatively rare condition, it is being reported with increasing
frequency in the medical literature. Clinicians need to be able to
recognize its manifestations in order to provide appropriate treatment
to their patients in a timely manner.
Table 5. Antibiotic Treatment
#
Viridans streptococci
9
Group B streptococcus
1
Group C streptococcus
3
Group F streptococcus
2
Coagulase negative staphylococci
3
Bacteroides fragilis
2
Staphylococcus aureus (MSSA)
1
Non-typeable H. influenzae
1
Eikenella spp.
1
Peptostreptococcus spp.
2
Prevotella intermedia
1
Fusobacterium spp.
1
Cultures were positive in 63% of the cases; the majority of the infections were polymicrobial. TABLE 4 shows the organisms
isolated. The most common organisms isolated included viridans Streptococci, Group C streptococci, Group F streptococci,
oral anaerobes, and Staphylococcal species. There was only one S. aureus isolate that was methicillin susceptible. No
MRSA was isolated in this group of patients.
3.
4.
5.
6.
In our series of the patients, the incidence of PPT cases seems to have increased over the last 5 years of the
study.
There is a clear male predominance especially in Black and Caucasian adolescents in association with
sinusitis.
Almost all cases in this series of pts were associated with severe intracranial extension of disease.
Disease is polymicrobial in the majority of cases with MRSA not found to be a causative agent.
Management involves a combination of prolonged antibiotic therapy and surgical drainage.
Outcomes are generally good although the severity of the infections seem to be worse in pts diagnosed during
the last 5 years of the study.
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2. Bambakis NC, Cohen AR: Intracranial Complications of Frontal Sinusitis in Children: Pott’s Puffy Tumor Revisited.
Pediatr Neurosurg 2001; 35:82-89.
3. Younis RT, Lazar RH, Anand VK: Intracranial Complications of Sinusitis: A 15-year Review of 39 cases. Ear, Nose,
Throat J 2002; 81(9):636-638, 640-642, 644.
4. Ademe N, Hedlund AM. Byington CL: Sinogenic Intracranial Empyema in Children. Pediatrics 2005; 116(3):e461e467.
5. Kombogiorgas D, Solanki GA: The Pott Puffy Tumor Revisited: Neurosurgical Implications of This Unforgotten
Entity. Case Report and Review of the Literature. J Neurosurg (2 Suppl Pediatrics) 2006; 105:143-149.
6. Hicks CW, Weber JG, Reid JR, Moodley M: Identifying and Managing Intracranial Complications of Sinusitis in
Children. A retrospective Series. Pediatr Infect Dis J 2011; 30(3):222-226.