Recurrent Pott's puffy tumor, a rare clinical entity

摘要

Sir, Pott's puffy tumor, a feature of osteomyelitis of the frontal bone, is a rare entity in post-antibiotic era. It has been reported in older children and very rarely in adults. A 29-year-old man met with a road traffic accident,causing open wound over forehead, 5 years back. He was operated by bicoronal flap approach, with obliteration of frontal sinus with fat. Five years after surgery, he had boggy forehead swelling, with intense pain. Local examination showed erythema and tense edema of the right upper lid, as well as forehead swelling measuring 8x6 cm [Figure 1]. There was thinning of skin, suggestive of pus under pressure with impending rupture of abscess. On palpation, warm, tender, fluctuating and doughy pitting edema in the region of frontal sinus was found, with breach in continuity in anterior wall of frontal sinus. Rest of the general examination revealed no abnormality. Twenty-five milliliters of thick, yellow-colored pus was aspirated. Pus culture grew Staphylococcus aureus, sensitive to levofloxacin. He was relieved on medical therapy and refused surgical intervention. After symptom-free period of 2 months, there was recurrence of swelling of forehead. Contrast computerized tomography (CE-CT) [Figures 2] showed soft tissue swelling and edema around the superior aspect of the right orbit with slight proptosis. There was breach in the continuity in anterior wall of frontal sinus with foamy foreign body-like material (later identified as fat). Posterior bony wall of frontal sinus was intact and thickened, suggesting chronic osteomyelitis. Frontal recess was clear; no discharge was seen on nasal endoscopy. Evacuation of pus, debridement of necrotic tissue, granulation and resection of osteomyelitic bone was done by osteoplastic flap technique. Using a 4-mm, 30-degree endoscope, frontal recess and frontal ostia were widened; sialastic drain was put for drainage of sinus through the nose. Reconstruction/ obliteration was deferred due to underlying oste...