종설1 종설2 원저1
증례1 원저2
증례2 증례3 증례4
1인제대학교 의과대학 해운대백병원 신경외과학교실, 2이비인후과학교실
양승현
1, 김용완
2, 김해유
11Department of Neurosurgery, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
2Department of Otorhinolaryngology-Head and Neck Surgery, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
Seung-Hyeon Yang
1, Yong Wan Kim
2, Hae Yu Kim
1내시경적 비강접근 농양배액술로 치료한 Pott’ s puffy tumor 1례
J Korean Skull Base Society 14권 1호 : 39~43, 2019
Pott’s puffy tumor is soft tissue swelling of the forehead due to subperiosteal edema and the accumulation of pus or granulation tissue. It is usually associated with osteomyelitis of the frontal bone secondary to frontal sinusitis. An 11-year-old boy was admitted with left periorbital swelling and pain that had become aggravated from 3 days prior. Orbital computed tomography revealed pansinusitis with osteomyelitis on the left orbital roof. He underwent magnetic resonance image that showed an extradural abscess approximately 1.9 x 1.5 cm in his anterior cranial fossa. His serum test revealed increased white blood cell counts and an elevated C-reactive protein level. We performed a middle meatal antrostomy and frontal sinusotomy via a transnasal endoscope. Coagulase-negative Staphylococcus was cultured from the pus within his frontal sinus. Antibiotic therapy was administered for 6 weeks. The patient’s epidural abscess and pansinusitis subsided completely. We report herein a rare case of Pott’s puffy tumor patient who was treated with a transnasal endoscopic sinusotomy and antibiotic therapy.
A case of Pott’ s puffy tumor treated via endoscopic intranasal drainage
논문 접수일 : 2019년 4월 25일 논문 완료일 : 2019년 5월 23일 주소 : Department of Neurosurgery,
Haeundae Paik Hospital, Inje University College of Medicine, 875, Haeun-daero, Haeundae-gu, Busan 48108, Korea Tel : +82-51-797-2090
Fax : +82-51-797-0840 교신저자
Hae Yu Kim
▒ INTRODUCTION
Sinusitis is a common disease that can occasionally lead to Pott’s puffy tumor that invades the frontal bone.
Pott’s puffy tumor is a clinical condition characterized by subperiosteal abscess formation with osteomyelitis. It requires rapid treatment including surgery to minimize potentially fatal sequelae.
This case report shows the usefulness of surgical drainage via the nasal endoscopic approach rather than craniotomy to treat Pott’s puffy tumor involving the left anterior cranial fossa. A nasal endoscopic approach was a good treatment option since it offered adequate drainage of the abscess and the benefits of a minimally invasive procedure.
▒ CASE REPORT
An 11-year-old boy with no unusual history visited the ophthalmology clinic with swelling of the left upper eyelid with pain and fever for 3 days prior. At admission, his vital signs were stable, and a visual field examination and visual acuity test elucidated no specific findings. An infection was suspected and prophylactic antibiotics were administered while testing. Orbit computed tomography (CT) was performed with contrast enhancement. There was a 1.9 x 1.6 cm bony destruction on the left superior
orbital wall and an abscessed suspicious lesion extending to the anterior cranial fossa. In addition, pansinusitis associated with the frontal, ethmoid, sphenoid, and maxilla sinus and body fluid retention and thickening of the left orbit was also seen (Fig. 1). Brain magnetic resonance imaging with enhancement performed on admission showed a 1.9 x 1.5 cm peripherally enhanced extra-axial nodular lesion in the anterior cranial fossa with bone destruction of the left superior orbital wall.
The brain parenchyma was not invaded (Fig. 2).
On the patient’s second day of hospitalization, a middle meatal antrostomy, frontal sinusotomy, and ethmoidectomy were performed via an endoscopic approach and polypoid changes including acute pus and bloody-black colored discharge were confirmed during the procedure. Abscess drainage and culture were performed during the operation. Immediately after surgery, dual antibiotic therapy was initiated. After the operation, the patient's edema and pain began to improve in his left eye. On a follow-up CT on the seventh day after surgery, his nodular soft tissue had gradually decreased (Fig. 3).
However, the culture result was reported as coagulase- negative Staphylococcus. Antibiotics were administered for 5 weeks. Antibiotic agent has not been changed after culture report because the cultured bacteria was sensitive to the current antibiotic agent. The patient was discharged and oral antibiotics (2nd generation Fig. 1
Computed tomography scan shows bone destruction in the left superior orbital wall with a nodular soft tissue lesion (approximately 1.9 × 1.6 cm on coronal scan) extending to the anterior cranial fossa and pansinusitis involving the frontal, ethmoid, sphenoid, and maxillary sinus.
A B
cephalosporin) were prescribed for 4 additional weeks.
At the last follow-up visit 2 months after surgery, no specific findings were observed on CT and treatment was terminated (Fig. 4).
▒ DISCUSSION
The discussion of Pott’s puffy tumors should begin with a precise definition of the term “sinusitis.” Rhinosinusitis is inflammation of the mucosa of the nasal and paranasal (ethmoidal and maxillary) sinus.[1] Monosinusitis refers
to inflammation localized to the maxillary sinus.[2]
Pansinusitis refers to the involvement of the frontal and sphenoidal sinus, including the ethmoidal and maxillary sinus.[2] It is also diagnosed through an image study, which indicates a wider range of progressive diseases that may involve otorhinolaryngologic surgery.[3]
Pott’s puffy tumors are defined as frontal subperiosteal abscesses.[3] The spread of infection from the sinus to the intracranial cavity usually follows thrombophlebitis of the diploic vein without a valve.[4-6] It is believed that the incidence of frontal sinusitis is high in this period
Fig. 3
A follow-up computed tomography scan on postoperative day 7 shows a decreased but remaining nodular soft tissue lesion with bone destruction in the left superior orbital wall without significant extension to the left anterior cranial fossa.
A B
Fig. 2
A B C
T1 gadolinium-enhanced magnetic resonance image shows a peripherally enhanced extra-axial nodular lesion in the anterior cranial fossa (approximately 1.9 × 1.5 cm on axial scan) with bone destruction in the left superior orbital wall and pansinusitis involving both the frontal, ethmoid, sphenoid, and maxillary sinus. T2-weighted image shows no parenchymal signal change.
because of the continuous growth of the frontal sinus in adolescence and the increased vascularity of the diploic vein.[5] Sinusitis occasionally causes osteomyelitis in the posterior table of the frontal sinus, leading to Pott’s puffy tumors due to direct involvement in the intracranial space.[4,6] Chronic frontal sinusitis and, rarely, trauma to the frontal area may also provoke Pott’s puffy tumors.
[3] The occurrence of Pott’s puffy tumor in this case caused by direct spread from sinusitis. However, the presence of Pott’s puffy tumors should be considered for another cause of infection even in patients with sinusitis because hematogenous spreading could be a cause of intracranial abscesses generally. There was no other cause in this case.
The widespread use of antibiotics and the rapid treatment of sinusitis have caused them to become increasingly rare diseases, but if they occur, they are a serious conditions requiring emergency surgical intervention.[6,7] Patients with Pott’s puffy tumors show predominantly frontal scalp swelling, headache, fever, nasal drainage, photophobia, and frontal sinus tenderness.[8,9] In some cases, tenderness or erythematous aspects are milder than the actual infected depth, which may make the correct diagnosis difficult.
[3] Periorbital swelling, persistent hyperthermia, and the failure of symptomatic treatment suggest that the infection has progressed to the intracranial cavity even
if neurological symptoms are not seen because typical epidural abscess presents with periorbital soft tissue swelling and often has no neurological symptoms.[8,9]
If a patient with epidural abscess shows neurological symptoms, this suggests parenchymal invasion of infection. The association of neurological symptoms is included in poor prognostic factors.[9,10]
It is difficult to rule out Pott’s puffy tumors with clinical symptoms without image studies. Through CT, the extent of bony detail invasion can be demonstrated.
Treatment with antibiotics alone is insufficient and surgical intervention is usually needed.[5,10] In addition, the prophylactic administration of anticonvulsants is recommended, and the administration of steroids is controversial but widely used.[10-12]
The patient herein had a 1.9 x 1.6 cm bone destruction anterior cranial fossa on the left superior orbital wall on orbit CT that was accompanied by frontal, ethmoid, sphenoid, and maxilla pansinusitis. Middle meatal antrostomy, frontal sinusotomy, and ethmoidectomy through an endoscopic approach were performed in otolaryngology, and natural pus drainage was induced in the operative field. The pus gradually diminished and the patient's left periorbital swelling improved.
Surgical removal of intracranial abscess is mainly performed via craniotomy. It is the most obvious removal method that allows direct access to the lesion site Fig. 4
A 2-month postoperative computed tomography scan shows the improved and decreased extent of the remaining nodular soft tissue lesion with bone destruction in the left superior orbital wall without significant extension to the left anterior cranial fossa.
A B
through skin incision. However, in the presented case, abscess was located in the anterior part and pus drainage of accompanying sinusitis was also necessary. Endoscopic surgical drainage of the frontal, ethmoid, sphenoid, and maxillary sinus was effective and it was possible to gain the advantage of inducing the natural drainage of the remnant pus without skin incision.
CONFLICT OF INTEREST
No potential conflict of interest relevant to this article was reported.
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