Presentation of Pott’s puffy tumor as an ophthalmic emergency

PURPOSE: Pott’s puffy tumor (PPT) is a rare complication of frontal sinusitis, which is characterized by osteomyelitis of the frontal bone with an associated subperiosteal abscess. We discuss here a rare presentation of this potentially life-threatening condition as an ophthalmic emergency, its diagnosis and multi-disciplinary approach to its effective management.

METHODS: A 50-year-old diabetic man was seen by the ophthalmologist at the emergency department for complaints of right sided painful swollen upper eyelid of 3 days duration. Initial computed tomography (CT) revealed pansinusitis, inflammatory dacryoadenitis and right sided pre-septal cellulitis. Bilateral endoscopic drainage of both middle meatus was done by Otorhinolaryngology colleagues. Subsequently, surgical drainage of secondary orbital abscess was performed by Ophthalmologist.  Klebsiella pneumoniae was isolated from the culture.  While being treated with antibiotics, anti-inflammatory medications and insulin in the ophthalmic ward of our general hospital, he developed seizures and was transferred to the critical care unit. Magnetic resonance imaging (MRI) demonstrated right frontal bone osteomyelitis together with a right frontal epidural abscess, orbital abscess, meningitis and cerebritis. He was treated with appropriate intravenous antibiotics and multidisciplinary team care at the critical care unit.

RESULTS: After 50 days of inpatient management, he recovered and was discharged in a stable condition, following successful management under the care of Ophthalmology, Critical Care Unit, Neurology, Endocrine and Otorhinolaryngology teams.

CONCLUSION: Pott’s puffy tumor can be fatal. It may present to an ophthalmologist with painful eyelid edema. In the occasion of severe orbital infection, which is resistant to conventional antibiotics, it is prudent to look for subtle signs of adjacent bone infection. Early detection and management can prevent spread of infection to adjacent intracranial system.

Timely diagnosis, and management of this rare condition is important to avert serious vision and life-threatening complications. Prompt multidisciplinary management is essential for optimal outcome.

KEYWORDS: Pott’s Puffy Tumor, meningitis, cerebritis, orbital cellulitis, eyelid edema

Dr. Chaw Hsu Win is a Resident Medical Officer in the Department of Ophthalmology at Raja Isteri Pengiran Anak Saleha (RIPAS) Hospital, Brunei Darussalam. She obtained her M.B., B.S. from Yangon, Myanmar in 2012 and subsequently completed the ChM in Clinical Ophthalmology at the University of Edinburgh and MRCS (Ed) Ophthalmology. Her professional interests include vitreoretinal diseases and oculoplastic surgery, with a particular interest in advancing her clinical knowledge and expertise in these subspecialties and pursuing opportunities in ophthalmic research.