July 20, 2007
Internal Medicine World Report, July 2007, Volume 0, Issue 0

Prepared by Shomeet V. Patel, MD, Harold P. Katner, MD, A. Rakesh Sarma, MD, and Edwin W. Grimsley, MD, Department of Internal Medicine, Mercer University School of Medicine, Macon, Ga

A 45-year-old man with a history of chronic alcohol abuse, pancreatitis, and chronic, untreated sinusitis presented to the emergency department with complaints of abdominal pain and intermittent right-sided throbbing headaches with nonradiating pain. Physical examination revealed a 3 × 3-cm nonpulsatile, nontender, fluctuant swelling over the right brow (Figure 1). Twenty-four hours after hospital admission, righteye ptosis was evident, accompanied by an increase in the size of the swelling to 4 × 5 cm.

What's Your Diagnosis?

Figure 1

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Frontal bone osteomyelitis—Also known as Pott's puffy tumor, this condition is defined as a subperiosteal abscess of the frontal bone associated with osteomyelitis. The introduction of antibiotics has rendered this condition a rare entity, most often presenting as a soft-tissue swelling overlying frontal bone osteomyelitis.

Bacteroides

Pott's puffy tumor most often shows a polymicrobial infection on culture. The predominant organisms are alpha- and beta-hemolytic streptococci, species, and staphylococci. Diagnosis requires a thorough radiologic workup, including computed tomography (CT) scans. Gallium scanning can help by indicating the amount of inflammatory activity in the bone. Treatment consists of aggressive debridement of necrotic bone and long-term culture-directed IV and oral antibiotics for a minimum of 6 weeks.

Despite the complete resolution of symptoms in this patient, a crater deformity remained, as seen on CT (Figure 2).

Figure 2—(A) Crater deformity of the frontal bone after successful treatment of Pott's puffy tumor. (B) CT scan demonstrating near-complete opacification and thickening of the frontal sinuses, with destruction of the outer table of the right frontal sinus and thinning of the inner table.