2. 13yo Male with no sig. PMHx presented to the ED complaining “there is a bump on my forehead”

3.  Duration: 2 days  Localization: Left forehead  Tender to palpation  Clear nasal discharge  No medications  No fever, HA, N/V, Visual changes, dizziness  No traumas or bug bites  Progression: Worsened over first day  Additional Hx: 1 month ago had a “big pimple” in the same area

4.  VS WNL  Well appearing  Facial Asymmetry  Palpable 8cm induration left forehead  Warm  No erythema  No fluctuance  No discharge  No Orbital swelling  Eyes: PERRLA, EOMI, no tenderness  Clear nasal discharge BL  Tenderness on BL Paranasal Sinuses  Rest of PE WNL

5.  Osteomyelitis of the frontal bone with Subperiostal Abscess, often seen as a complication of Frontal Sinusitis  First described in 1760 by Sir Percivall Pott, patient presented with Subperiostal Abscess and Extradural Empyema

6.  Frontal Sinusitis, most common  Trauma  Skin infections/Bites  Intranasal Cocaine/Methampheta mine abuse  Mastoiditis  Malignancies  Craniotomy  More common in Males

7.  Well appearing to Ill appearing  Signs of URI infection anywhere from 2 days to 14 days  Low grade fever 38-38.5C  HA, Nausea, Vomiting  Sinus tenderness  Swelling Forehead, mid forehead more common, with erythema, fluctuance, and tenderness  Altered Sensorium  Hx of previous Abx is common

8.  Clinical: High index of suspicion  CBC WBC>15.000, left shift  Elevated ESR/CRP  Elevated WBC and Protein CSF  Imaging: › US › Head CT C- › Size of the abscess, extent of involvement. Orbit also should be scanned in the presence of preseptal cellulitis or in patients in whom vision / ocular movement is compromised.

9.  Imaging › Nuclear Scanning: Delineate Bone infection › CT C+: Brain involvement

10. Subdural and subcutaneous temporal empyema Frontal and temporal empyema and fluid accumulation in frontal sinus

11. Complications Differential Dx  Meningitis  Venous sinus thrombosis  Subdural abscess  Epidural abscess  Brain abscess  Preseptal Cellulitis  Septal Cellulitis

12.  Broad spectrum Antibiotics 6-8 weeks  Drainage Neurosurgery/ENT  Riedel’s procedure: This procedure is indicated in patients with intracranial complications. This procedure involves complete removal of posterior table of frontal sinus with cranialization of frontal sinus. This is followed by removal of anterior table, causing prolapse of forehead skin into the frontal sinus cavity. Reconstruction of forehead can be performed using: 1. Split calvarial bone grafts 2. Polymethyl – methacrylate 3. Hydroxyapatite 4. Titanium mesh

13.  Trephination of Frontal Sinus  Cranialization of Frontal Sinus

14. Head CT C-: Soft tissue swelling overlying the left frontal bone

15.  A mother brings her 3-year-old daughter in for evaluation. She enrolled her daughter in child care 1 week ago. Over the past 3 days, the child has experienced yellowish rhinorrhea and cough. Her appetite has remained good, and her highest temperature has been 37.3°C. On physical examination, the child is interactive and playful. Her tympanic membranes are normal bilaterally, but yellowish rhinorrhea is visible in both nares. The remainder of the physical examination findings are unremarkable. You order a sinus radiograph series, which shows bilateral maxillary mucosal thickening with opacification of the ethmoid sinuses. Of the following, the MOST appropriate next therapy is: A. Amoxicillin orally B. Azithromycin orally C. Ceftriaxone intramuscularly D. Observation E. Trimethoprim-sulfamethoxazole orally Answer: D Viral URI

16.  Rani Haider, Helen; Mayatepec, Hernan; Schaper, Jorg; Vogel, Markus. Pott's puffy tumor: a forgotten differential diagnosis of frontal swelling of the forehead. Journal of Pediatric Surgery Vol 47, Issue 10, October 2012, Pages 1919–1921  Chaudhary, Subhash; Mogal, Survana; Suwan, Phillip. Pott’s Puffy Tumor: An Uncommon Clinical Entity Case Reports in Pediatrics Vol 2012 (2012), Article ID 386104  Vanderveken OM, De Smet K, Dogan-Duyar S, Desimpelaere J, Duval EL, De Praeter M, Van Rompaey D. Pott's puffy tumour in a 5-year old boy: the role of ultrasound and contrast-enhanced CT imaging; surgical case report. B-ENT. 2012;8(2):127-9  Wald, Ellen. Acute bacterial rhinosinusitis in children: Clinical features and diagnosis. Up to Date

17. Thank you…