69 years old male, presented to ED feeling unwell, confused, with an acute onset of forehead swelling of 1-week duration, that got worse in the last 24 h.
There was also a history of recurrent sinusitis.
Observations in ED:
P: 125, BP: 95/55, RR: 28, Sat: 94% OA. GCS 13/15
Here is a photo of the forehead lump with permission from the patient.
What is the most likely diagnosis?
Diagnosis:
Looking at the presentation & the location & shape of the swelling, the most likely diagnosis here is "Pott’s Puffy Tumour"
Overview:
It is a rare, non-neoplastic complication of frontal sinusitis or trauma.
It is osteomyelitis of the frontal bone with associated subperiosteal abscess.
It was first described by Sir Percival Pott in 1768.
Often polymicrobial, with streptococci, staphylococci, and anaerobic bacteria, Hence, antibiotic coverage should include gram-positive and anaerobes.
Clinical presentation:
Symptoms include headache, periorbital swelling, fever, purulent rhinorrhoea, & vomiting.
Signs of meningitis or encephalitis.
Intracranial complications occur either due to direct extension or venous drainage.
Complications:
include meningitis, epidural, subdural abscess, & venous sinus thrombosis.
If the inferior wall of the frontal sinus is involved, infection may spread to the orbits, causing either orbital cellulitis or intra-orbital abscess.
Investigations:
CT/MRI are required for diagnosis (Misdiagnosing as a simple infected skin cyst can be fatal).
"Here is the CT of the head of this patient, shared with his permission"
Treatment:
Surgical drainage, is the standard of care.
Broad-spectrum antibiotics for 4 to 6 weeks.
Here is a link to a video that discusses the above case with some more details:
Thanks a lot for your efforts
Totally agree: we can't see what we don't know
Thanks Boss for another interesting and informative one. 🙏