Pott's Puffy Tumor in a 12-year-old boy

DR. TIANJIANG YE: A 12-year-old boy with a history of attention deficit hyperactivity disorder and asthma was referred from an outside facility for evaluation of a headache and an abnormal head CT scan. The patient was playing soccer 3 days prior to presentation when he was elbowed by an opposing player in the forehead, just above his left eyebrow. The patient denied any loss of consciousness but subsequently developed intermittent headaches, nausea, and malaise, which became progressively worse over the next few days. A review of systems was negative for visual changes, weakness, numbness, tingling, nuchal rigidity, or vomiting. His mother reported he had an upper respiratory infection approximately 2 weeks prior to presentation, and he continued to have some congestion. The mother also noted swelling above the left supraorbital ridge where he was elbowed, and the patient was brought to an urgent care clinic three days later for evaluation of ongoing headaches and inability to concentrate at school. A CT scan of his brain was obtained at the outside facility and he was noted to have a focal lucency in the left frontal region of his brain concerning for a subdural hematoma. He was transferred to the Hasbro Children’s Hospital ED for further evaluation and management. At triage, the patient ‘s blood pressure was 116/71 mm Hg, pulse 106 beats per minute, respiratory rate of 22, temperature of 100.4 F, and pulse oximetry of 100% on room air. The patient appeared well and was cooperative and able to answer questions appropriately. He had a moderate area of focal swelling over his left supraorbital ridge with mild tenderness to palpation. His extraocular movements were intact and painless. Pupils were equal and reactive. His neurological exam, including cranial nerve, sensory, motor, reflex, cerebellar, and gait was normal. His nasal mucosa was moist and he had mild turbinate hypertrophy and tenderness to palpation over his frontal sinus. He did not have any nuchal rigidity or lymphadenopathy. His heart, lung and abdominal exam were unremarkable and his extremities were warm and well perfused. The remainder of the exam was unremarkable.