Pott’s puffy tumor, described by British surgeon Sir Percival Pott, is a polymicrobial infection that has become less common with adequate antibiotic treatment [1]. The term tumor refers to one of the 4 components of the inflammation (tumor) and not neoplasia [1]. Although it may be secondary to head trauma, it generally occurs following untreated or poorly treated frontal sinusitis [1]. This pathology is frequently seen in patients between 6-15 with a male predominance [1], due to increased vascularization and growth of the frontal sinuses at this age [1].

Frontal sinusitis can have intra and extra cranial complications following hematogenous dissemination, through the rich diploic venous networks and septic embolism [1,2], or the direct extension of infection, through the posterior wall causing epidural/subdural empyema, brain abscess, or meningitis, through the anterior wall causing subperiosteal abscess, or through the inferior wall with orbital complications [1,2]. Note that the most common orbital complications, occurring in 29% of cases, are preseptal and periorbital cellulitis. However, intraorbital abscesses are very rare [2]. The most common clinical signs are forehead swelling, headache, fever, nasal congestion or purulent/non-purulent secretions [1,3,4]. A soft, erythematous forehead swelling associated with fever is considered pathognomonic for Pott’s tumour [1].

In some cases fever may be absent, and other signs may be associated including orbital swelling, nausea/vomiting and meningeal syndrome [1]. In our case, the patient presented to the emergency department for two frontal and orbital swellings with a history of headaches and nasal congestion. Fever was absent in our setting. He subsequently benefited from an injected cerebral-ocular CT scan, although MRI remains the examination of choice with its high soft tissue resolution, best characterizing the extent of the infection [1,5,6] CT showed pansinusitis complicated by osfrontal osteomyelitis, frontal lobe empyema and preseptal cellulitis.

The literature has confirmed that intracranial complications, with or without bone erosion, have been observed in 60% to 85% of cases [5,6] and may be asymptomatic until late in their evolution, especially when “silent” areas of the central nervous system such as the frontal lobe are involved [6].

The most commun microorganisms are non-enterococci streptococci (47%), anaerobic bacteria (28%), staphylococci (22%) [7]. In our case, the culture was sterile, but direct examination revealed objective a gram positive cocci in chain.

The management of swollen pott’s tumor is multidisciplinary; it consists of medical treatment, with broad-spectrum antibiotic therapy administered intraveinous as soon as possible. The combination of ceftriaxone and clindamycin can be used to treat frontal sinusitis. In the case of Staphylococcus aureus (MRSA) which is generally resistant to clindamycin, vancomycin should be used in addition to ceftriaxone [8-10]. Combination therapy with vancomycin, ceftriaxone, and metronidazole covers most intracranial pathogens complicating acute bacterial sinusitis. In this case, metronidazole was chosen to be added to ceftriaxone and ciprofloxacin initially because of his good diffusion in the bones. A previous study showed that sinus related intracranial epidural abscesses in children could be managed without neurosurgical procedures in the setting of adequate sinus drainage, appropriate antibiotic therapy and minimal extradural mass effect from the abscess [11].