Pott Puffy Tumor

Headache and Frontal Mass • Xray of the Week 2016 • Week #36

16 year old male with headache and right frontal palpable mass. What is the diagnosis? What is the eponymous name for the condition at the site of the blue arrow?

Figure 1. A: CT axial image. Large osseous defect of posterior wall of the right frontal sinus and a small region of lysis in the anterior right frontal sinus. Figure 1. B: MRI- T1 weighted axial with contrast. Mild right frontal dural enhancement adjacent to the peripherally enhancing abscess in the right frontal sinus/epidural space. Enhancement of the edematous frontal scalp indicates Pott puffy tumor.

Figure 1. C: MRI- T2 weighted axial. Abscess in the right frontal sinus/epidural space.

Figure 1. D: MRI- T1 sagittal with contrast. Mild right frontal dural enhancement adjacent to the peripherally enhancing abscess in the right frontal sinus/epidural space.

Figure 1. E: MRI- Diffusion weighted axial image. Restricted diffusion centered in the right frontal sinus.

Figure 1. F: MRI- ADC map axial image. Confirms restricted diffusion centered in the right frontal sinus due to abscess.

In 1760, English surgeon Sir Percival Pott, described the condition of frontal sinusitis with subperiosteal abscess and osteomyelitis. Inflammatory extension into the scalp soft tissues results in the non-neoplastic "tumor" in the frontal region. Most commonly seen in adolescents, this is now a rare complication of sinusitis due to early treatment with antibiotics. Of note, Sir Pott also first described arthritic tuberculosis of the spine, now known as Pott disease.

As seen in this case, CT scan and MRI demonstrate fluid in the frontal sinus with edema of the adjacent scalp, and a lytic portion of the anterior wall of the sinus. (Fig. 1A) In this case, there is also dural enhancement (Fig. 1D) and an epidural abscess. (Fig. 1B-F) Contrast enhanced CT or MRI may demonstrate other intracranial complications such as, subdural empyema, dural sinus thrombosis, and cerebral abscess. Dural enhancement is seen better on MRI than CT and is indicative of meningitis. A scalp abscess with rim enhancement may also be visualized. The clinical appearance is a frontal palpable erythematous painful mass (Fig. 2). Surgical treatment is required with drainage of the abscess and 6 weeks of IV antibiotics.

Figure 2: Tweet from @CMAJ showing the clinical appearance of Pott Puffy Tumor.

References:

1. Masterson L, Leong P. Pott's puffy tumour: a forgotten complication of frontal sinus disease. Oral Maxillofac Surg. 2009 Jun;13(2):115-7.

2. Karaman E, Hacizade Y, Isildak H et-al. Pott's puffy tumor. J Craniofac Surg. 2008;19 (6): 1694-7.

3. Durur-subasi I, Kantarci M, Karakaya A et-al. Pott's puffy tumor: multidetector computed tomography findings. J Craniofac Surg. 2008;19 (6): 1697-9.

4. Morón FE, Morriss MC, Jones JJ et-al. Lumps and bumps on the head in children: use of CT and MR imaging in solving the clinical diagnostic dilemma. Radiographics. 24 (6): 1655-74.

Kevin M. Rice, MD serves as the Medical Director of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice launched Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field.

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