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    Four-year-old boy with headache, swollen forehead


    A 4-year-old boy presents to your clinic one autumn, along with his mom and dad, with a 6-month history of headaches and the recent appearance of a tender lump in the middle of his forehead. His parents report that the headaches have been episodic and bifrontal. The pain is localized to just above the bridge of his nose and radiates between his eyes to his scalp.

    He asks for the room to be darkened because the light hurts his eyes. He has had a runny nose this spring and summer, which mom and dad attribute to seasonal allergies. He denies head trauma. He has obvious periorbital edema and also a doughy swelling over his glabella. He is not febrile.

    The boy was admitted to the children's hospital 20 days ago for a case of severe sinusitis. He presented to the emergency department at that time with fever, headache, irritability, photophobia, and new nonfluctuant forehead swelling. You review the blood work from that evaluation. The white blood cell count was elevated at 20,000 cells per liter (normal, 4,500 to 10,000 cells/L) and left shifted with 73% granulocytes and 0.4% bands. The erythrocyte sedimentation rate was 24 mm/hr (normal, 0-10 mm/hr) and C-reactive protein was 2.7 mg/dL (normal, 0-0.9 mg/dL). Two peripheral blood cultures yielded no growth.

    You review the head and sinus computed tomography (CT) scans obtained during the admission and readily appreciate the severe pansinusitis and marked thinning of the lateral walls of the ethmoid air cells. Midline soft tissue swelling was present anterior to the frontal sinuses, but no erosion into these structures was evident. There was no abscess.

    The patient was treated with 4 days of intravenous piperacillin-tazobactam, oral phenylephrine, and nasal oxymetazoline in the hospital. The mother says that both the headache and the swelling transiently improved with these interventions. He was discharged home to complete a 21-day course of amoxicillin-clavulanate. The headaches and forehead swelling improved.

    Digging a little deeper

    You further investigate by obtaining a detailed headache history. Headaches began 6 months ago and initially occurred twice per week. They begin in the midafternoon and last approximately one-half to 1 full hour. For the past 2 months, the headaches have occurred almost daily. They begin suddenly. The headaches occasionally wake the patient from sleep.

    There is no associated nausea or vomiting. By his parents' report, there has been no altered mental status. They deny cognitive or behavioral regression. There have been no changes in gait or baseline energy.

    Nine weeks ago, the patient began to experience intermittent fevers approximately 3 times per week, with a maximum temperature of 40°C. The fevers resolve by late evening.

    The patient has been evaluated on numerous occasions by his primary care pediatrician for the headaches and the fevers and was referred to neurology because of the increased frequency of paroxysmal headaches. An electroencephalogram was found to be normal.

    On this day

    You are seeing the patient today because his forehead swelling and headaches returned after 3 weeks. The family completed the amoxicillin-clavulanate course 1 week ago, but the patient's headache and photophobia recurred 2 days ago. The forehead swelling was noted at bedtime yesterday. The patient also reports that he wasn't able to see out of his right eye twice that morning. He says he can see fine now. He has had no fever since hospital discharge. He has had no nausea or vomiting.

    Happy patient, concerned doctor

    The energetic patient runs around the room as though nothing were wrong. He is afebrile, with a normal growth curve. His vital signs are within normal range for his age. He is oriented to time, place, and person. His memory is intact, and his speech is fluent. You palpate a 3 cm × 3 cm, well-circumscribed, skin-colored, fluctuant, tender midline forehead mass. He has mild periorbital swelling.

    Alarmed by the history of right-sided vision loss, you perform a thorough eye exam. The pupils are equal, round, and reactive to light. There is full ocular motility. There is no conjunctivitis. There is no nystagmus or ptosis. Using a panoptic ophthalmoscope, you confirm that the retinas appear normal, and the disks are sharp. The tympanic membranes, ear canals, and periauricular tissues are normal. The mastoid process is nontender and nonedematous. The boy has excellent dentition. His neck is supple. Lymphadenopathy is absent. The remainder of his neurologic and physical examination is unremarkable.

    Differential diagnosis

    Table: Differential diagnosis of midline forehead swelling
    You take a moment and think carefully about what could be causing this boy's forehead swelling (Table).1 You wonder whether the patient has a remote traumatic injury predisposing to an infected hematoma. You consider a soft-tissue infection such as a carbuncle or an infected sebaceous cyst or osteomyelitis. You place benign tumors, including dermoid cyst, lipoma, or giant frontal sinus mucocele, on the differential. Malignancy also is a possibility.

    The history of vision loss makes you very concerned about intracranial involvement. The bilateral periorbital edema signals spread of the disease process inferiorly along the frontal bone. Although this patient's sinuses are not fully developed, you remember that frontal sinuses are forming by 2 years of age as the ethmoidal air cells extend anteriorly and superiorly.

    Although direct erosion of the frontal bone could have theoretically occurred, you are also concerned about the valveless aspect of the frontal sinus venous drainage system, because those veins communicate with the venous plexus of the dura and periosteum of the periorbital and cranial spaces.2

    You are concerned that in addition to local spread of frontal sinus infection, septic thrombi could have freely migrated to the epidural region. You are worried that the patient could have a purulent epidural collection or abscess. You expand your differential to include possible intracranial abnormalities such as subdural empyema, brain abscess, or cortical vein thromboses. You proceed with an urgent brain and sinus CT scan.

    While the patient is in the scanner, you review his past medical history. The patient was born at term by cesarean delivery because of failure to progress. Before his recent hospitalization, the patient has had no prior admissions. He has mild eczema. He has a 2-year-old brother who is healthy. No other family members have had recent infections. Both parents have allergic rhinitis. He has never traveled outside of the country. He lives in a rural setting and enjoys watching NASCAR.

    The picture becomes clearer

    Figure: The red arrow points to frontal bone enhancement (osteomyelitis of the frontal bone). The blue arrow shows the frontal soft tissue abscess. (IMAGE COURTESY OF AUTHOR)
    The CT scan shows persistent right-sided frontal and maxillary sinus disease. The frontal soft tissue swelling has increased, with interval development of frontal bone osteomyelitis and a small intracranial, extra-axial abscess adjacent to the osteomyelitis. You call the radiologist to discuss the results, and she recommends magnetic resonance imaging (MRI). The MRI confirms bony erosion involving the midline frontal bone with a 3 cm × 1.5 cm, frontal, soft-tissue abscess. There clearly is an osteomyelitis of the frontal bone extending to the orbital roofs bilaterally (Figure). A 2 cm × 2 cm epidural abscess is noted. You are relieved to see that the adjacent brain parenchyma appears normal.

    You start vancomycin and ceftazidime empirically at the higher doses that are appropriate for central nervous system involvement. Your antibiotics cover the most common organisms isolated in pediatric sinusitis, namely Staphylococcus aureus, Streptococcus pneumoniae, nontypeable Haemophilus influenzae, Moraxella catarrhalis, alpha-hemolytic streptococcal species, and anaerobes.

    Hospital course

    You admit the patient to the hospital and consult the pediatric otolaryngology and neurosurgical services. Your patient undergoes needle drainage of the frontal abscess on the second hospital day. Aerobic and anaerobic cultures of the abscess material were sterile, presumably from prior antibiotic therapy. A repeat MRI revealed that the intracranial abscess responded very quickly to conservative management.

    You observe the child for 1 week in the hospital, and he has no fever or headache. The frontal swelling is noticeably improved. He is discharged home with a peripherally inserted central catheter line to complete a 6-week course of outpatient intravenous antibiotics.

    Otolaryngology and neurosurgery follow the patient closely during his hospitalization. The patient may ultimately require sinus debridement as an outpatient.

    Pott's puffy tumor

    You've determined that this boy has a case of Pott's puffy tumor. The triad of forehead swelling, frontal bone osteomyelitis, and epidural abscess was initially described in 1775 by the London surgeon Sir Percivall Pott.3,4

    Your patient's headache, fever, and forehead edema in the setting of chronic sinusitis is classic for Pott's puffy tumor. It can be complicated by suppurative extension intracranially, resulting in altered mental status, seizures, and focal neurologic deficits.5 Prompt diagnosis is essential. Sinus radiographs and CT are useful to identify the presence of sinusitis and frontal bone osteomyelitis, but MRI often is necessary to demonstrate the accompanying intracranial abscess.6

    Frontal bone osteomyelitis is a relatively rare entity in the antibiotic era, particularly in otherwise healthy children. Your patient also is younger than the typical adolescent age when Pott's puffy tumor usually occurs.7

    Although this complication typically is the result of trauma or direct extension frontal sinusitis, Pott's puffy tumor also has been reported as a result of insect bites, forehead acupuncture, subacute mastoiditis, dental abscess, and ethmoid sinusitis. Anaerobes, including fusobacterium species, have often been recovered from patients having Pott's puffy tumor.8,9 Treatment plan should involve collaboration of infectious disease specialists, otolaryngologists, and neurosurgeons.

    Pott's puffy tumor should be suspected in patients with headache and forehead edema. (Pott was able to clinically diagnose this condition in the 18th century without radiographic benefit.)

    A high index of suspicion is required to make the diagnosis. Prompt neuroimaging, initiation of appropriate antibiotics, and multispecialty collaboration result in favorable outcomes.

    Our patient

    The patient completed a total of 12 weeks of antibiotic treatment. He is much improved and currently not experiencing headaches, orbital pain or visual changes, or sinonasal symptoms. A recent MRI scan revealed resolution of the fluid collection.

    DR WEAVER a second-year pediatric resident at Children's Hospital of the King's Daughters, Norfolk, Virginia. DR MAURIELLO is an infectious disease fellow at Children's Hospital of the King's Daughters, Norfolk. DR SIBERRY is an assistant professor of pediatrics in the divisions of general pediatrics and adolescent medicine and pediatric infectious diseases at Johns Hopkins Hospital, Baltimore. The authors and section editor have nothing to disclose in regard to affiliations with, or financial interest in, any organizations that may have an interest in any part of this article. For reasons of confidentiality, the child pictured in the photo is not the child discussed in the Puzzler vignette.


    1. Sabatiello M, Vanhooteghem O, Mostinckx S, De La Brassinne M. The Pott's puffy tumor: an unusual complication of frontal sinusitis, methods for its detection. Pediatr Dermatol. 2010;27(4):406-408.

    2. Bambakidis NC, Cohen AR. Intracranial complications of frontal sinusitis in children: Pott's puffy tumor revisited. Pediatr Neurosurg. 2001;35(2):82-89.

    3. Pott P. Observations on the Nature and Consequences of Wounds and Contusions of the Head, Fractures of the Skull, Concussions of the Brain, &c. London: 1760.

    4. Flamm ES. Percivall Pott: an 18th century neurosurgeon. J Neurosurg. 1992;76(2):319-326.

    5. Adame N, Hedlund G, Byington CL. Sinogenic intracranial empyema in children. Pediatrics. 2005;116(3):e461-e467.

    6. Durur-Subasi I, Kantarci M, Karakaya A, Orbak Z, Ogul H, Alp H. Pott's puffy tumor: multidetector computed tomography findings. J Craniofac Surg. 2008;19(6):1697-1699.

    7. Pender ES. Pott's puffy tumor: a complication of frontal sinusitis. Pediatr Emerg Care. 1990;6(4):280-284.

    8. Blackman SC, Schleiss MR. Forehead swelling caused by Pott's puffy tumor in a 9-year-old boy with sinusitis. Pediatr Int. 2005;47(6):704-707.

    9. Karaman E, Hacizade Y, Isildak H, Kaytaz A. Pott's puffy tumor. J Craniofac Surg. 2008;19(6):1694-1697.


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