Author(s)
Shuhui Xu, MBBS,MRCS(Ireland), MMed(ORL)
Neville Wei
Yang Teo, Senior Consultant
Li Shan Sng, Medical Officer
Affiliation(s)
Singapore General Hospital;
Abstract:
Case details
A 46-year-old Chinese female presented with a
gradually enlarging forehead swelling over
several months. The impression of the initial
attending was a forehead lipoma and it was
conservatively managed. She then developed
pain and rapid swelling and re-presented to the
Emergency Department. On examination, a 5cm
left paramedian soft forehead swelling was seen
and nasoendoscopy showed purulent discharge
from bilateral middle meati with no polyps.
CT scan revealed a left frontal bone
subperiosteal abscess with marked surrounding
bony sclerosis and pansinusitis. There was a
1cm2 defect through the anterior table as well as
a sub-centimeter area of posterior table erosion
with no intracranial involvement.
She underwent emergent endoscopic sinus
surgery and drainage of the abscess cavity. Intraoperatively,
copious pus was drained, and a
narrow bony canal was seen communicating the
abscess cavity and frontal sinus drainage
pathway. This was expanded with rongeurs and
drills and decision was made for a stent. A 3mm
biliary T-tube was inserted via a supra-brow
insertion, its horizontal limb sitting within the
abscess cavity and vertical limb in the frontal
ostium.
She was given 6 weeks of culture-directed
antibiotic therapy.
The tube was removed a month later in the
operating theatre. There was a patent track with
no pus seen within the abscess cavity.
Follow-up nasoendoscopies showed progressive
narrowing of the abscess drainage pathway after
removal of the T-tube. However, she remained
asymptomatic, and the sinus cavities remained
clear.
Discussion:
Pott’s Puffy Tumor is a rare entity requiring both
surgical and medical management. Maintaining
a high index of suspicion and early intervention
is key to reducing complications. In this case,
chronic inflammation resulted in marked
sclerosis around the abscess cavity and difficulty
in maintaining sinus patency. The biliary T-tube
worked well as a stent for the configuration of
this abscess, however the underlying disease
process still resulted in eventual stenosis.
Other surgical options include a modified
endoscopic Lothrop or osteoplastic flap, but
whether they are undertaken upfront or as a
delayed procedure will require shared decision
making.