1
It’s just a bump on her forehead!
Introduction
Facial swelling is a commonly encountered complaint in the pediatric emergency department
with a wide range of possible differential diagnosis. Some of the possible causes, such as
osteomyelitis, require time-sensitive interventions and hence the recognition of these in the
emergency department becomes important. This case report is of an 11-year old female patient
who came into the emergency department with acute inflammatory facial swelling and was
diagnosed to have frontal sinus osteomyelitis or Pott’s Puffy tumor.
Case Description
An 11-year girl was brought into the emergency department by her mother with complaints of
progressive facial swelling since the last 8 hours. The patient was also having a right-sided
periorbital headache since the last one week, and a mild fever since the last four days. She also
had two episodes of vomiting a few hours ago. On close questioning, the child agreed to have
bumped her head onto the wall while running in the house. The patient denied cough or nasal
congestion, vertigo, photophobia or blurry vision. Past medical and surgical history was
unremarkable. Vitals on presentation were normal except for a fever of 101 F. On physical
examination, there was a single 5x5 cm, roughly midline, circular, tender swelling without
surrounding erythema or signs of inflammation. There was bilateral maxillary sinus tenderness.
Neurological examination was normal.
Investigations were significant for a white count of 11290/uL with neutrophilic leukocytosis,
ESR of 82 mm/hr and a CRP of 9.8 mg/dL. Plain CT scan of head performed in the emergency
department was significant for right-sided frontal and maxillary sinusitis with superficial soft
tissue swelling. Due to a high clinical suspicion of frontal sinus osteomyelitis, the patient was
referred for emergent MRI and neurosurgery consultation. Subsequent MRI scan revealed right
frontal sinusitis with associated osteomyelitis, epidural abscess, dural enhancement, and
overlying subcutaneous abscess, with a trans-osseous extension of the frontal sinus into the
subcutaneous tissue as well as into the epidural space. Functional endoscopic sinus surgery was
performed for frontal sinus drainage. A PICC line was placed and IV Ceftriaxone and IV
Metronidazole were administered for six weeks. The patient reported improvement and the mass
was resolved during the hospital stay.
Discussion
Facial swelling in pediatric patients can have a wide differential diagnosis(1). These could be
classified into four groups based on history and physical examination findings: Acute swelling
with inflammation (lymphadenitis, sinusitis, and osteomyelitis), non-progressive swelling
(congenital anomalies such as cephalocele and dermoid), slowly progressive swelling
(neurofibroma or vascular malformations) and rapidly progressive swelling (malignancies such
2
as rhabdomyosarcoma or Ewing’s sarcoma). Most of the pediatric facial swellings encountered
in the emergency department belong to the former category and the preferred modality of
imaging is a contrast-enhanced CT.
Pott’s Puffy tumor is a non-neoplastic complication of sinusitis characterized by sub-periosteal
abscess of the frontal bone (2). In the initial stages, they may be misdiagnosed for a simple
infected skin cyst(3). In pediatric populations, identifying the high-risk swellings that require
imaging is important. Red flags in the history and physical examination that may warrant further
imaging are a progressive frontal headache, frontal swelling, fever, and neurological signs(4).
The prevalence of this condition is on the rise probably due to increased prevalence of partially
treated chronic sinusitis(5). Delay in diagnosis could lead to serious intracranial complications
such as epidural abscess, intracranial abscess and pre-septal orbital cellulitis(6).
Conclusion
This case study highlights the need to investigate non-specific facial swellings with potentially
life-threatening causes in mind. A high amount of clinical suspicion is key to appropriate
imaging and early recognition of serious complications of sinusitis, such as Pott’s Puffy tumor.
References
1. Khanna G, Sato Y, Smith RJH, Bauman NM, Nerad J. Causes of facial swelling in pediatric
patients: correlation of clinical and radiologic findings. Radiogr Rev Publ Radiol Soc N Am
Inc. 2006 Feb;26(1):157–71.
2. Sørensen HB, Bille AG. [Pott’s puffy tumour is a rare complication of sinusitis]. Ugeskr
Laeger. 2014 Apr 7;176(15).
3. Ball SL, Carrie S. Pott’s puffy tumour: a forgotten diagnosis. BMJ Case Rep [Internet]. 2015
Sep 29;2015. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4593294/
4. Ball SL, Carrie S. Complications of rhinosinusitis. BMJ. 2016 Feb 26;352:i795.
5. Kombogiorgas D, Solanki GA. The Pott puffy tumor revisited: neurosurgical implications of
this unforgotten entity. Case report and review of the literature. J Neurosurg. 2006
Aug;105(2 Suppl):143–9.
6. Palabiyik FB, Yazici Z, Cetin B, Celebi S, Hacimustafaoglu M. Pott Puffy Tumor in
Children: A Rare Emergency Clinical Entity. J Craniofac Surg. 2016 May;27(3):e313-316.