Sinusitis is a pathological process of which Pott's tumour can be a complication, posing a very high risk due to the possibility of widespread intracranial complications. The first symptoms of sinusitis and Pott's tumour are non-specific, making antibiotic therapy a common treatment attempt. Unfortunately, it can mask or delay the appearance of specific symptoms, and early diagnosis and treatment is crucial in terms of possible complications.
Sinusitis is a pathological condition frequently encountered in otolaryngology practice, and both frontal and paranasal sinusitis can be referred to. The most common symptoms are pain in the frontal area, which is exacerbated when bending over or olfactory disturbances. Pott's tumour is understood to be an inflammation of the bone and bone marrow in the frontal bone (which was initially described as a consequence of trauma) with swelling visible in these areas. As clinical practice indicates, the appearance of Pott's tumour can also be a consequence of inflammation of the sinuses (frontal and paranasal). In the situation of a tumour, a prompt and accurate diagnosis and early treatment are very important, as the intracranial complications caused by the tumour can be extensive and very dangerous [1].
Sinusitis
Inflammation of the mucous membrane of the nasal cavity and sinuses is a very important health problem. Due to the number of cases and the spread in the population of this pathological phenomenon, it can be concluded that it is a significant problem in terms of public health, i.e. from an epidemiological point of view, but also in terms of cost and financial burden [3].
How is sinusitis defined and what is it?
According to the guidelines, sinusitis is defined as an inflammatory condition that must show at least 2 symptoms, one of which should be a feeling of nasal obstruction and discharge. In addition to this, at least 1 of the following symptoms should be present: facial pain/discomfort, olfactory disturbances, concomitant polyps, mucopurulent discharge, the appearance of nasal mucosal oedema or changes in CT imaging [4].
What is Pott's tumour?
Osteomyelitis of the frontal bone with concomitant accumulation of pus in the subperiosteal space, manifested by swelling in the frontal region, is called Pott's tumour. Its occurrence is closely associated with untreated or poorly treated sinusitis and can lead to very extensive and severe intracranial complications. The specialist literature on this topic focuses mainly on case reports, and the age group most commonly affected is children. Of the 115 cases described up to 2017, 74 were children and only 41 were adults.
Creation of
Pott's tumour is the pathological condition most commonly seen as a complication of inflammation of the frontal sinuses and this applies to both acute and chronic inflammation. In the vast majority of cases, inflammation of more than one sin us is revealed during the diagnostic process, as the maxillary and ethmoid sinuses may also be involved. Estimating and referring to statistics, it can be said that, proportionally, in as many as 75% of cases Pott's tumour is a complication of sinusitis, and in the remaining 15% of cases it is a consequence of trauma. Other cited causes of Pott's tumour include mastoiditis, insect bites, the use of acupuncture, a history of otitis media, periorbital inflammation, hair transplantation or a congestive cyst of the frontal sinuses [1].
Scale of the problem
A pathological condition such as Pott's tumour does not have an age restriction; however, referring to statistics, it can be seen that, among the incidences, people in their teens are most commonly recorded with a trend towards the male sex. The highest number of diagnoses occurs in the 11th year of life, which is explained by a greater tendency to contract upper respiratory tract infections, which are often associated with sinusitis, as well as the specific structure of the frontal sinuses during this developmental period. There are, of course, cases indicating deviations from this age "norm" for the occurrence of a tumour - indeed, a case has been described of a child aged 7 weeks in whom the appearance of a tumour was associated with the onset of septicaemia [1].
photo: panthermedia
How does the pathological process of tumour formation proceed?
To understand this question, it is necessary to start with the structure of the sinuses, which are formed from the frontal cells of the sieve bone in the space between the inner and outer lamina of the frontal bone. The development of the frontal sinuses takes place between the ages of 2 and 12-15, and they become visible on X-rays at the earliest after the age of 6. When there is a disorder such as inflammation in the frontal sinuses, there is an increased risk of osteomyelitis, the most common complication of which is Pott's tumour. This is because when there is inflammation of the sinuses, there is a likelihood that it will expand anteriorly, which can cause destruction of the frontal cortex. This is a direct cause of the accumulation of pus content under the periosteum, resulting in the swelling visible in the frontal area. If, on the other hand, the inflammation spreads towards the posterior wall of the frontal sinus, it can lead to meningitis or the formation of epidural and subdural abscesses. Another way in which the infection spreads is through blood-borne dissemination, when the mucosa present in the sinuses is drained by the non-capillary veins forming anastomoses with the subdural venous plexus along with the periosteal veins. Infected material thus easily enters the vein and invades the bone structure, resulting in osteomyelitis, encephalitis or venous sinus thrombosis [1].
#STRONA#
Osteomyelitis is a mechanism by which all elements of the bone tissue are involved, where both systemic and local factors are important. There is an activation of the bone remodelling process, a violation of the bone structure (which can also occur in the case of mechanical damage), but the mechanism itself is unknown. It is presumed that under the influence of the pathogen, more inflammatory mediators and cytokines are produced, which stimulate osteoblasts [2].
The most visible and noticeable symptom is the appearance of swelling in the frontal region, but Pott's tumour is characterised by a whole set of symptoms. The swelling itself is characteristic - it is well demarcated, soft, shows no signs of soreness, and has a specific location, i.e. on the forehead or top of the head. Other less specific symptoms also appear, such as headaches, fever, nasal congestion or a feeling of general fatigue. The lack of specificity of the initial symptoms is often the reason for the administration of an antibiotic, which, in this case, may involve delaying the appearance of specific symptoms or, worse, masking them - as this does not allow an early diagnosis of the problem of a spreading intracranial infection. Symptoms such as convulsions, severe apathy, disturbances of consciousness or vision, aphasia along with nerve paralysis, are signs that are already indicative of the complications and havoc caused by an intracranial infection.
Diagnosis and tests
Due to the lack of specificity of the first symptoms exhibited by Pott's tumour, making an accurate diagnosis is quite a challenge for the doctor. It is therefore necessary to undertake a differential diagnostic procedure to exclude sinusitis, angioedema, any insect bites, soft tissue inflammation, cough, haemangioma or lipoma.
In the examinations themselves, abnormalities mainly depend on the progression of the disease and its severity, and the most common findings are an elevated white blood cell count and elevated CRP, which, however, is not a specific indicator but only indicates ongoing inflammation in the body. Cerebrospinal fluid (CSF) collection does not work well in this condition either, as it does not show any specific abnormalities.
The test that confirms the presence of inflammation in the sinuses is the CT scan and MRI (magnetic resonance imaging), which shows 100% success rate for detecting intracranial abscesses.
To confirm unequivocally the presence of a Pott's tumour, it is necessary to collect and examine the nasal secretions for bacteriology. The purulent content of the tumour itself should also be subjected to this procedure, obtained by puncturing the tumour cavity.
Treatment scheme
The treatment process is divided into 2 stages - the first is the use of broad-spectrum antibiotic therapy, followed by neurosurgical measures. As there is insufficient data, no recommendation has been created at this date relating to the stages and sequence of treatment for the detection of Pott's tumour.
The treatment regimen outlined above is relatively successful, as most patients recover and do not show signs of neurological complications, although some patients develop aphasia, seizures or paralysis of selected muscle groups [1].