A 63 yo male with HIV presents with diplopia and the images shown

What do the images show?

Our patient had a Pott’s puffy tumor.

Actually, the Pott’s tumor isn’t always puffy.  It was described by Sir Percivall Pott in 1760and is a subperiosteal abscess associated with osteomyelitis of the frontal bone. This can result in a swelling on the forehead but can also spread inwards leading to an intracranial abscess as in our  patient.

Sinusitis can be associated with sudural empyema as in our case or venous thrombosis, epidural abscess  periorbital cellulitis, or brain abscess because of septic emboli propagating through the venous system.

While Pott’s puffy tumor is uncommon, sinusitis is very common  affecting 35 million people a year in the US.  It is divided into acute lasting less than 4 weeks, and sub-acute (up the 12 weeks) and chronic (more than 12 weeks.

Only 0.5-2% of sinus infections are bacterial and benefit from antibiotics.  Thevast majority of fungal sinusitis is non-invasive and allergic in nature, but invasive fungal sinusitis i.e. Mucor , is seen in the immune suppressed and diabetic population. 

Risk factors for sinusitis include disorders of mucociliary clearance as in cystic fibrosis or Kartagener’s, Churg Strauss, cycloosygenase -2 polymorphism, orpolymorphisms in the tumor necrosis factor alph-induced protein 3(TNFAIP3) gene.  Asthmatics as a group tend to have more sinusitis. 


Our patient had an ethmoid sinusitis and frontal sinusitis with cortical erosion of the roof of the R ethmoid air cells and the roof of the R orbit.  There was cortical destruction in the anterior cranial fossa involving the cribriform plate and subdural empyema. The reason for his diplopia was  erosion into the medial right extraconal space extending to the orbital apex. He  underwent R maxillary antrostomy, right anterior and posterior ethomoidectomy and right spenoidotomy.  His cultures grew only MRSA.  He is currently awaiting a second debridement and continues on IV antibiotics.

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Karaman E. Hacizade Y, Isildak H, Pott’s puffy tumor. 2008 . J Craniofac Surg. 19: 1694-7.


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Montone KT, Livolsi VA, Feldman MD, Palmer J, et al. Fungal rhinosinusitis : a retrospective microbiologic and patholiogic review of 400 patients at a single university medical center. Int J Otolaryngol. 2012: 2012:684835. Doi: 10.1155/2012/684835.