Baylor University Medical Center Proceedings April 2017 - 180

reduction. A CT scan with contrast
can be performed if there is a high
suspicion of intracranial extension.
Intracranial complications with or
without direct erosion of the frontal
bone have been observed in about
60% to 85% of these patients (5,
7). Tsai et al reported a 100% rate
of intracranial complications in their
six pediatric patients with Pott puﬀy
tumor (8). Ketenci et al indicated
that intracranial complications are
often present during a regimen of
antibiotics and are often asymptomatic when the abscess is localized
Figure 2. (a) Sagittal T2 fluid-attenuated inversion recovery and (b) axial contrast-enhanced T1-weighted images in a silent area of the central nervous
show frontal sinusitis (smaller arrow), frontal bone defect (curved arrow), and frontal epidural collection (longer system (5, 9, 10).
arrow) with peripheral rim enhancement (larger double arrows) suggestive of epidural abscess. A small subperiosteal
CT scan can demonstrate siabscess is also noted in the frontal soft tissues (smaller double arrows).
nusitis, bone erosion, subperiosteal
collection, and intracranial extenare often polymicrobial, with streptococci, staphylococci, and
sion. In our case, CT showed frontal sinusitis, bone erosion,
anaerobic bacteria, as they favor lower oxygen concentrations.
subperiosteal collection, and extradural abscess. As with other
Hence, antibiotic coverage should include gram-positive and
intracranial pathologies, MRI is the modality of choice (11, 12).
anaerobes (5). In the present case, the organism was Streptococcus
MRI can better delineate intracranial pathology, dural sinus
intermedius.
thrombosis, and bone edema. Abscesses show restricted diﬀuSymptoms include headache, periorbital swelling, fever,
sion (13, 14) on diﬀusion-weighted sequences, indicating thick
purulent rhinorrhea, vomiting, and signs of meningitis or enviscous pus. In this case, MRI showed frontal bone edema and
cephalitis. Intracranial complications occur either due to direct
extradural abscess, without dural venous sinus or meningeal inextension or venous drainage. Complications include meningivolvement. MRI is helpful particularly in follow-up after meditis; epidural, subdural, or intraparenchymal abscess; and caverncal or surgical management, reducing overall radiation exposure.
ous sinus and dural venous sinus thrombosis (5). If the inferior
Bone scintigraphy with Tc-mMP may be more sensitive than
wall of the frontal sinus is involved, infection may spread to the
CT in detection of early osteomyelitis, but its sensitivity is poor
orbits, causing either orbital cellulitis or intraorbital abscess (6).
in the setting of acute sinusitis (15).
Our patient presented with frontal swelling and headache
Early diagnosis and treatment of Pott puﬀy tumor is necesin the emergency department and received a CT. Although
sary. Broad-spectrum antibiotics for 4 to 6 weeks, along with
CT scans have a higher radiation dose, at most centers like
surgical drainage, is the standard of care. This patient underwent
ours, MRI scanners are not available around the clock. Parfrontal craniotomy and functional endoscopic sinus surgery
ticular attention should be paid to decrease the radiation dose
in addition to 4 weeks of antibiotics. Follow-up MRI showed
by strictly following the pediatric protocols for radiation dose
complete resolution.
b

Figure 3. Postoperative postcontrast (a) axial and (b) sagittal MRI images show resolution of the extradural abscess
and frontal sinus infection. The burr holes (arrows) are related to surgical evacuation of the abscess.
180

Baylor University Medical Center Proceedings

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Pott's puﬀy tumor: a dangerous sign for

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