(BMJ)—A 16-year-old boy presented with a 2-week hx of forehead and eyelid swelling. He reported hitting his head against a wall while asleep 2 weeks prior and presented to the ED on 2 earlier occasions. Exam: soft, tender, bilateral frontal and periorbital swelling; vital signs WNL. Dx confirmed by CT. What’s the dx?
Hematoma
Subgaleal hemorrhage
Orbital cellulitis
Ewing sarcoma
Pott puffy tumor
You are correct. A contrast CT demonstrated a large subgaleal, rim-enhancing collection overlying the frontal bone and osteomyelitis of the left frontal bone—classic findings of Pott puffy tumor (PPT). PPT can occur as a complication of acute or chronic sinusitis or head injury and can be associated with life-threatening intracranial complications. The mechanism from the hx was unlikely to produce the degree of swelling and bruising to the forehead. Furthermore, it was soft and very tender to light touch, suggesting an infective process rather than a hematoma.

While contrast-enhanced CT can demonstrate collections and bony changes characteristic of PPT, MRI is the gold standard for detecting intracranial pathology and bony edema. Management consists of prompt broad-spectrum antibiotics and definitive drainage of the collection. This patient was given broad-spectrum antibiotics and underwent surgical drainage overnight.

Despite being a rare entity, PPT should be considered in patients presenting with forehead swelling.

Emergency Medicine Journal 2021;38:348-370