Photo Quiz

An Abscess on the Forehead


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Am Fam Physician. 2007 Jan 15;75(2):243-244.

A 10-year-old girl presented with a one-week history of a lump on her forehead. It was initially thought to be an infected sebaceous cyst (Figure 1). Review of symptoms revealed a three-month history of nasal discharge and frontal headaches but was otherwise negative. She had been diagnosed previously with sinusitis and treated with a two-week course of amoxicillin.

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Figure 1.

An abscess on the forehead.


Figure 1.

An abscess on the forehead.

Question

Based on the patient's history and physical examination, which one of the following is the most likely diagnosis?

A. Carbuncle.

B. Infected sebaceous cyst.

C. Hematoma.

D. Pott's puffy tumor.

E. Inflammatory cutaneous tuberculosis.

Discussion

The answer is D: Pott's puffy tumor. In children, bacterial sinusitis may complicate an upper respiratory tract infection. In most cases, this resolves without further problems. Frontal osteomyelitis secondary to frontal sinusitis (Pott's puffy tumor) is rare in the antibiotic era,1,2 but it can result in serious consequences.

Patients present with frontal scalp swelling and also may have headache, fever, nasal drainage, and frontal sinus tenderness. If the condition progresses, neurologic complications such as hemiparesis, obtundation, pupillary dilatation, aphasia, or intracranial abscess can develop.1 Early diagnosis can be achieved with the use of computed tomography3 (Figure 2). Contrast-enhanced magnetic resonance imaging may be necessary to rule out intracranial empyema.4

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Figure 2.

Computed tomographic scan showing osteomyelitis causing bony erosion through the front and back of the frontal sinus.


Figure 2.

Computed tomographic scan showing osteomyelitis causing bony erosion through the front and back of the frontal sinus.

Treatment of patients with Pott's puffy tumor should include surgical drainage and antibiotic therapy.13 Antibiotics should be directed against typical upper respiratory pathogens (e.g., streptococcus) and anaerobic pathogens until culture and sensitivity results are available.2

A carbuncle is a simple skin infection that is locally painful and tender. It would not cause headaches or nasal discharge and would be uncommon in a healthy young girl. Carbuncles often discharge pus from multiple sites.

A sebaceous cyst is usually evident to the patient as a painless lump. Furthermore, it should be present for a while before becoming infected. Cysts also may rupture, causing an intense inflammatory reaction that is difficult to distinguish from an acute infection.

The history given by the patient and her mother was not suspicious for a hematoma. There were no surrounding ecchymoses, and the overlying skin was intact. Furthermore, she had no history of trauma or coagulopathy.

There was no previous exposure to or inoculation with tuberculosis or a history of foreign travel. The patient was previously healthy and was not immunocompromised. Cutaneous tuberculosis would not be associated with symptoms of headache or nasal discharge.

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Selected Differential Diagnosis of a Mass on the Forehead

Condition Characteristics

Carbuncle

Painful and tender swelling of the skin caused by bacterial infection (commonly Staphylococcus aureus); may be fluctuant and/or discharge pus; there is often surrounding inflammation or cellulitis

Infected sebaceous cyst

Common in hair-bearing skin, especially over the face, neck, and trunk; usually slow-growing and painless but will become painful if infected

Hematoma

Associated with a history of trauma and most likely to have a sudden onset of swelling after injury; a surrounding area of ecchymosis may be visible

Pott's puffy tumor

Frontal scalp swelling caused by frontal osteomyelitis with a bone defect and an epidural collection; symptoms include headache, fever, nasal drainage, and frontal sinus tenderness; if the condition progresses, neurologic complications may develop

Inflammatory cutaneous tuberculosis

Low incidence; most often occurs in endemic areas; more common among immunocompromised patients

Selected Differential Diagnosis of a Mass on the Forehead

Condition Characteristics

Carbuncle

Painful and tender swelling of the skin caused by bacterial infection (commonly Staphylococcus aureus); may be fluctuant and/or discharge pus; there is often surrounding inflammation or cellulitis

Infected sebaceous cyst

Common in hair-bearing skin, especially over the face, neck, and trunk; usually slow-growing and painless but will become painful if infected

Hematoma

Associated with a history of trauma and most likely to have a sudden onset of swelling after injury; a surrounding area of ecchymosis may be visible

Pott's puffy tumor

Frontal scalp swelling caused by frontal osteomyelitis with a bone defect and an epidural collection; symptoms include headache, fever, nasal drainage, and frontal sinus tenderness; if the condition progresses, neurologic complications may develop

Inflammatory cutaneous tuberculosis

Low incidence; most often occurs in endemic areas; more common among immunocompromised patients

The author would like to acknowledge Dr. R. Davies (Radiologist) and Mr. G. Weiner and Mr. S. McDonald (ENT team) for their roles in the diagnosis and treatment of this patient.

REFERENCES

1. Bambakidis NC, Cohen AR. Intracranial complications of frontal sinusitis in children: Pott's puffy tumor revisited. Pediatr Neurosurg. 2001;35:82–9.

2. Gupta M, El-Hakim H, Bhargava R, Mehta V. Pott's puffy tumour in a pre-adolescent child: the youngest reported in the post-antibiotic era. Int J Pediatr Otorhinolaryngol. 2004;54:267–8.

3. Mammen-Prasad E, Murillo JL, Titelbaum JA. Infectious disease rounds: Pott's puffy tumor with intracranial complications. N J Med. 1992;89:537–9.

4. Adame N, Hedlund G, Byington CL. Sinogenic intracranial empyema in children. Pediatrics. 2005;116:e461–7.

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