Pott's puffy tumor in the post-COVID era

Pott's puffy tumor (PPT) is an intracranial complication of frontal sinusitis. It commonly presents with headache and periorbital swelling. It may also involve devastating clinical complications including seizures and status epilepticus, sagittal sinus thrombosis, and hemiplegia. Surgical intervention entails craniotomy with exenteration of the frontal sinuses with a prolonged course of antibiotics. Full recovery can be expected in most cases unless delayed diagnostic workup causes irreparable damage to the brain. Recently, an increase in PPT cases has been observed following the COVID-19 pandemic. We present our findings from 2020 to 2024 on the demographics and medical details of patients treated at a major US tertiary-referral center, encompassing clinical, radiographic, diagnostic, surgical, and outcome data.

We retrospectively reviewed the cases treated at the Johns Hopkins Children's Hospital. IRB approval was obtained prior to initiating data collection. The primary outcome was recovery status (full recovery, partial recovery, death). Additionally, we sought to characterize our cohort, reporting symptom onset, clinical presentation, diagnostic workup, preoperative medication, surgical approach, length of stay, and antibiotic treatment duration.

Between January 2020 and April 2024, 24 patients with Pott's puffy tumor were treated. Most patients were boys (ratio 17:7), with common symptoms including recent sinusitis (75%), periorbital swelling (71%), and fever (63%), while 33.3% presented with seizures. Most patients underwent bifrontal craniotomy and exenteration of the frontal sinuses, with the majority achieving full recovery (92%). One patient experienced partial recovery and one patient had a fatal outcome due to a prior history of malignancy. Mean follow-up was 31.2 weeks.

Early surgical intervention and broad-spectrum antibiotics are the mainstay of treatment for patients presenting with Pott's puffy tumor. Only one patient was previously diagnosed with COVID-19, suggesting no causal pathophysiological link. Our cohort contributes to the ongoing investigation of an increase in reported PPT cases in the USA by outlining the clinical and outcome characteristics of the largest reported PPT cohort to date. In the post-COVID era, an increase in cases warrants raising awareness for an overlooked disease entity which is critical to establishing the best care available in this patient population.