Concealed Beneath the Swelling: Diagnosing Pott’s Puffy Tumour

Peter Awad, Mark Awad, John Awad

Learning points

  • Pott’s puffy tumour is a rare but potentially life-threatening complication of frontal sinusitis
  • Children presenting with forehead swelling and periorbital oedema should be carefully assessed for underlying sinus disease and intracranial complications
  • Ophthalmologists may be the first clinicians to encounter these patients owing to their orbital manifestations
  • Periorbital oedema should not automatically be attributed to preseptal cellulitis.
  • Early imaging, including CT and MRI are important to delineate the extent of intracranial extension
  • Prompt multidisciplinary team management with intravenous antibiotics and surgical drainage can prevent serious neurological and ophthalmic sequelae

Background

Pott’s puffy tumour (PPT) is a rare complication of frontal sinusitis characterised by frontal bone osteomyelitis and subperiosteal abscess formation (1,2). Although first described by Sir Percival Pott in 1760 following head trauma, the condition is now most associated with frontal sinus infection (3). It occurs predominantly in children and adolescents owing to increased vascularity of the diploic venous system during this period of development (2,4).

Patients typically present with forehead swelling, headache, fever and signs of sinusitis. However, ophthalmic manifestations including periorbital oedema, ptosis, diplopia and proptosis may be the initial presenting feature (5). Early recognition is essential as delayed diagnosis can result in serious complications, including epidural abscesses, subdural empyema, meningitis, cerebral abscess, and dural venous sinus thrombosis (1,6).

Cross-sectional imaging with CT and MRI plays a pivotal role in the diagnosis and assessment of intracranial extension (5). Management requires prompt intravenous antibiotics and often surgical intervention involving a multidisciplinary team comprising ophthalmology, otolaryngology, neurology and paediatrics.

In this article, we describe a child presenting to the ophthalmology department with periorbital swelling who was subsequently diagnosed with a Pott’s puffy tumour. This case highlights the importance of maintaining a high index of suspicion for orbital and intracranial complications of sinus disease in children presenting with seemingly uncomplicated eyelid swelling.

Case Presentation

A 12-year-old boy presented to the ophthalmology department with a four-day history of progressive swelling around his right eye associated with forehead swelling, frontal headache and malaise. His parents reported a preceding one-week history of coryzal symptoms and nasal congestion. There was no history of trauma.

On examination, the patient was pyrexial at 38.3°C, visual acuity was 6/6 bilaterally with normal colour vision and pupillary responses. There was marked oedema of the right upper eyelid and a fluctuant, tender swelling over the right forehead. Mild right-sided ptosis and periorbital erythema was also noted; ocular motility was not limited, there was no proptosis or relative afferent pupillary defect and fundoscopy was also unremarkable.

Bloods showed raised inflammatory markers with a white cell count of 18.6 x 109/L and a C-reactive protein of 146mg/L.

Given the combination of forehead swelling and periorbital oedema, an urgent CT of the orbit and paranasal sinuses was performed. This demonstrated an opacification of the frontal and ethmoidal sinuses with erosion of the anterior table of the frontal sinus and an overlying subperiosteal collection, consistent with a Pott’s puffy tumour. There was also evidence of a small epidural collection adjacent to the frontal bone.

An MRI was then undertaken and confirmed frontal bone osteomyelitis, subperiosteal abscess and a small epidural abscess. There was no evidence of cerebral abscess formation or dural venous sinus thrombosis.

The patient was commenced on broad-spectrum intravenous antibiotics including ceftriaxone, metronidazole and flucloxacillin. Following multidisciplinary team discussion between ophthalmology, otolaryngology, paediatrics and neurosurgery the patient underwent endoscopic sinus surgery with drainage of the frontal sinus and evacuation of the subperiosteal abscess.

Cultures returned showing streptococcus anginosus, and antibiotics were tailored accordingly. The patient made an excellent clinical recovery with complete symptom resolution. At six-week follow-up, his visual acuity remained 6/6 with no residual ophthalmic sequelae.

Discussion

Pott’s puffy tumour is an uncommon diagnosis but remains an important consideration in children presenting with forehead swelling and periorbital oedema (1). The condition develops when infection spreads from the frontal sinus through the diploic veins to involve the frontal bone, resulting in osteomyelitis and subperiosteal abscess formation (2, 4).

The majority of patients present with fever, headache and forehead swelling. Although ophthalmic manifestations alone may be the patient’s presenting complaint (5). Periorbital oedema can easily be mistaken for periorbital cellulitis, potentially delaying diagnosis and increasing the risk of intracranial complications (7).

Intracranial complications occur in up to 60- 85% of cases of PPT, because of this, intracranial imaging is essential when assessing the extent of disease (8).

CT remains the preferred initial imaging modality owing to its excellent assessment of bony anatomy and paranasal sinus disease; however, MRI provides superior delineation of intracranial extension and soft tissue involvement.

Pott’s puffy tumour management requires prolonged intravenous antibiotic therapy and, in most cases, surgical drainage of the infected sinuses and associated collections. A multidisciplinary approach is often necessary to optimise outcomes.

This case highlights the importance of considering PPT in children presenting to ophthalmology with forehead swelling and periorbital oedema, particularly when accompanied by systemic/coryzal symptoms.

References

  1. Kombogiorgas, D., & Solanki, G. A. (2006). The Pott puffy tumor revisited: neurosurgical implications of this unforgotten entity. Case report and review of the literature. Journal of neurosurgery, 105(2 Suppl), 143–149. https://doi.org/10.3171/ped.2006.105.2.143
  2. Tsai, B. Y., Lin, K. L., Lin, T. Y., Chiu, C. H., Lee, W. J., Hsia, S. H., Wu, C. T., & Wang, H. S. (2010). Pott’s puffy tumor in children. Child’s nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery, 26(1), 53–60. https://doi.org/10.1007/s00381-009-0954-z
  3. Flamm ES. Percivall Pott: an 18th century neurosurgeon. J Neurosurg 76: 319-326, 1992.
  4. Sandoval JI, Hohman MH, De Jesus O. Pott Puffy Tumor. [Updated 2025 Feb 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560789/
  5. Yamamoto, H., Kuroda, H., Hiroi, T., Hasuike, T., Doi, A., & Nishioka, H. (2025). Pott’s Puffy Tumor Initially Presenting as Eyelid Swelling without Typical Forehead Swelling. Internal medicine (Tokyo, Japan), 64(12), 1921–1925. https://doi.org/10.2169/internalmedicine.4525-24
  6. Masterson, L., & Leong, P. (2009). Pott’s puffy tumour: a forgotten complication of frontal sinus disease. Oral and maxillofacial surgery, 13(2), 115–117. https://doi.org/10.1007/s10006-009-0155-7
  7. Lamoreau, K. P., & Fanciullo, L. M. (2008). Pott’s puffy tumour mimicking preseptal cellulitis. Clinical & experimental optometry, 91(4), 400–402. https://doi.org/10.1111/j.1444-0938.2007.00234.x
  8. Sandoval JI, Hohman MH, De Jesus O. Pott Puffy Tumor. [Updated 2025 Feb 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560789/

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