images in clinical medicine
The new england journal of medicine
n engl j med 370;11 nejm.org march 13, 2014
ity on physical examination. A blood chemical profile showed a C-reactive protein level of 29 mg per liter and a white-
cell count of 11,900 per cubic millimeter. Computed tomography revealed unilateral opacification of the left frontal
and ethmoid sinuses (Panel B, white and green arrows, respectively) as well as defects in the frontal bone (Panel B,
blue arrow). T2-weighted axial magnetic resonance images (MRIs) showed a subperiosteal abscess in the forehead
(Panel C, arrow) and a 3 cm × 5 cm × 8 cm epidural abscess (Panel D, arrow). There was no involvement of the venous
sinuses. A combined neurosurgical and otolaryngologic approach was used to surgically manage the frontal sinusitis
and associated epidural abscess. Cultures grew Streptococcus intermedius. The patient was treated with intravenous anti-
biotic agents for 4 weeks after surgery. He remained well, with no neurologic sequelae or residual abscess observed
clinically or on follow-up MRI obtained 1 month after drainage. Pott’s puffy tumor is a rare clinical entity character-
ized by osteomyelitis of the frontal bone and associated subperiosteal abscess, usually related to frontal sinusitis;
intracranial extension is a potential complication.
previously healthy 13-year-old boy presented to the otorhinolaryngology clinic with
soft, well-demarcated, painless swelling of the forehead (Panel A, arrow). He had no definite symptoms of
sinusitis but had had a headache and fluctuating fever for 3 weeks. He had no neurologic deficit or abnormal-
Copyright © 2014 Massachusetts Medical Society.
Lindsey R. Baden, M.D., Editor
Frontal Sinusitis Causing Epidural Abscess
and Puffy Tumor
Taija Kristina Nicoli, M.D.
Antti Mäkitie, M.D., Ph.D.
Helsinki University Central Hospital
The New England Journal of Medicine
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