Purpose or Case Report: A nine year old female presents to the emergency room with midline forehead soft tissue swelling. One month prior she experienced a period of identical swelling without any other associated event. After three days, the swelling spontaneously resolved. She continued to be asymptomatic until the morning of this admission when she woke up with swelling in the same location as one month prior. She again denied any other symptoms.
Methods & Materials: Using a high resolution transducer soft tissues of the forehead can be evaluated. In the presence of a calvarial defect over the sinus, intra sinus imaging can also be performed. It is vital to understand criteria seen in Pott's Puffy Tumor (PPT) so accurate diagnosis with ultrasound can be successful.
PPT is a complication of acute frontal sinusitis and is a surgical emergency due to life threatening intracranial complications. Due to advances in antibiotics PPT is very rare with a higher incidence in adolescence. This non-neoplastic tumor is characterized by osteomyelitis that erodes the wall of the affected sinus. Resultant subperiosteal abscess creates a puffy appearance within the soft tissues. Potential complications of PPT include intracranial invasion and venous sinus thrombosis.
Results: Sonographically, a hypoechoic region with increased peripheral vascularity measuring 2.3cm in transverse X 0.7cm in AP dimensions was seen. The collection appeared to emerge from the outer table of the frontal bone. The area continued deep to the outer table and contained mid-level echoes, likely representing PPT. A linear echogenicity was noted at the posterior aspect, presumed to reflect the posterior wall of the sinus.
CT with contrast revealed left frontal/ ethmoid sinus opacification with a cortical defect in the anterior frontal sinus and a subperiosteal abscess, PPT, in the overlying soft tissues and an intact posterior wall of the sinus.
MRI did not reveal any incidence of posterior wall erosion or intracranial abscess.
The following day the patient went to surgery for left endoscopic frontal sinusotomy, sinus trephination and drainage of PPT. Purulent material was found within the left ethmoid cavity and frontal sinus. Final microbiology revealed Staph aureus.
Conclusions: Typical imaging of PPT includes CT and MRI, but as the Image Gently campaign gains popularity sonography is the initial method of analysis. Sonography played a crucial role in the diagnosis and positive outcome of this patient by accurately identifying PPT resulting in prompt follow up care.