Скачать или смотреть Case study 19 - Pott’s Puffy Tumor explained by a Neurosurgeon - BRAIN INFECTION

Case study 19 - How can a simple sinus infection turn into multiple brain surgeries? The answer is Pott's Puffy Tumor.

In this particular case, it is Natasha Alyena Gunther who has used her TikTok to shed awareness on this topic. @natasha_santana97

#pottspuffytumor #craniotomy #sinusitis #brainsurgery #neurosurgery #casestudy

Introduction

Pott puffy tumor (PPT) describes a forehead edema resulting from osteomyelitis of the frontal bone with associated subperiosteal abscess. First described by Sir Percival Pott in 1768, a surgeon in London. Initially the word tumor represented one of the four components of inflammation described by Aulus Cornelius Celsus; rubor (redness), tumor (swelling), calor (warmth), and dolor (pain). The tumor in this case refers to the observable swelling of the forehead, rather than to any neoplasia.

When originally described, it was thought to be caused by a complication from direct trauma to the forehead. It is now known that it most frequently occurs as a complication of frontal sinusitis, most commonly seen in young adolescents. It is characterized by a circumscribed, tender swelling at the forehead presenting with other associated signs and symptoms including fever, headache, nasal discharge, or increased intracranial pressure. Early diagnosis and treatment of this condition are crucial for optimal outcomes.

Causes

Sinonasal infection: The most common cause of this rare complication of acute or chronic frontal or ethmoid sinusitis. Sinusitis occurs in 1 out of every 8 people in the United States and most of the time, resolves uneventfully. Only 0.5% to 2% of patients develop bacterial sinusitis and of these, 80% resolve without antibiotics. In rare instances untreated bacterial sinusitis can lead to serious complications, such as PPT.
Trauma: Head trauma, especially to the frontal area, is the second most common cause. PPT occurs by direct extension of wound infection or contamination, and not through secondary septic thrombophlebitis.
Less Common Causes

Cranial/frontal surgery
Dental infection
Cocaine abuse
Wrestling injuries
Insect bites
Risk factors that affect the normal immune response and can influence the development of PPT include diabetes mellitus, chronic renal failure, and aplastic anemia, as well as other causes of immunosuppression.

In most instances this is polymicrobial infection. The most common organisms encountered include non-enterococci streptococci (47%), anaerobic oral bacterial (28%), staphylococci (22%). Less common organisms that have been reported include Fusobacterium, H. Influenza, Enterococcus, Pseudomonas, Escherechia Coli, Pasteurella multocida, Proteus, and Bacteroides.

The rapid diagnosis and treatment of this condition are crucial for reducing the risk of development of complications and to optimize outcomes. Numerous studies have demonstrated the best strategy for management of Pott puffy tumor is the combination of medical treatment with systemic antibiotics and surgical treatment to drain abscesses, debride devitalized tissue, and restore sinus drainage.

Once the patient arrives and PPT is suspected, the patient should be admitted and started on broad-spectrum intravenous (IV) antibiotics, IV hydration, analgesia, and rapid coordination for imaging studies. Once the diagnosis is confirmed, otolaryngology and neurosurgical consultation should be obtained.

Broad-Spectrum IV Antibiotics: Should begin as soon as the diagnosis is suspected. Coverage for the most common pathogens, including Gram-positive and anaerobes, is required. It is essential to choose antibiotics that have adequate blood-brain barrier penetration for intracranial coverage. Choices include penicillins or vancomycin, 3rd generation cephalosporin, and metronidazole. Once the culture results are available, broad-spectrum antibiotics can be changed to more targeted therapy. The length of treatment varies but is prolonged, often 4-8 weeks of IV antibiotic therapy postoperatively. Some small extradural collections are often treated with IV antibiotics, but aspiration/biopsy is highly recommended to obtain culture and guide antibiotic therapy.

Surgery: Surgical options include an open approach or a minimally invasive technique (endoscopic intranasal frontal sinusotomy). The goal of surgery is to drain the sinus and excise the infected bone; this is extremely important to obtain a successful treatment. Traditionally, an open approach was the standard of care due to better visualization of the frontal recess, but it can result in significant cosmetic deformity. With recent advances in technique and experience, endoscopic intranasal frontal sinusotomy is not more widely used. The endoscopic approach has significantly less morbidity and mortality, shorter convalescent period, and no external scarring. Patients with anatomical variations causing PPT require surgical intervention. Surgery options will depend on image findings, including the location and extent of disease.