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ACEP Now: July 2026FIGURE 1: A 9-year-old boy with forehead swelling. (Click to enlarge.)
A 9-year-old, fully vaccinated boy presented to the emergency department (ED) accompanied by his mother for forehead swelling. He had a minor fall and hit his head about two weeks prior without loss of consciousness or vomiting. Four days later, the mother noticed the swelling had not improved despite applying ice. They denied any fevers, headaches, erythema, or neurological changes. He had no past medical history, medications, allergies, or prior surgeries.
On exam, the patient was in no acute distress and was well-appearing, with normal vital signs. He had a large focal area of edema to the anterior forehead with overlying fluctuance and without any skin changes (Figure 1). He has no other signs of trauma and a normal neurological exam.
FIGURES 2A, 2B: A CT head scan without contrast sagittal and coronal view showing findings consistent with bilateral frontal sinus sinusitis, osteomyelitis of the outer table and overlapping scalp abscess. A questionable tiny left anterior frontal epidural extension of scalp abscess. (Click to enlarge.)
In the ED, patients are frequently evaluated for minor head injuries. Persistent swelling, especially when accompanied by pain and/or fever, should raise suspicion for a deeper infection, though the presentation can be subtle. Early management is essential due to the risk of rapid progression to intracranial complications. A computed tomography (CT) scan in this patient was consistent with Pott puffy tumor (PPT).
PPT is a rare subperiosteal abscess of the forehead typically associated with underlying frontal bone osteomyelitis. Most commonly this polymicrobial infection occurs as a complication of sinusitis. However, it can also be caused by forehead trauma, insect bites, acupuncture, and malignancy. PPT can affect all age groups, but it is more likely among children ages 6 to 15. This is because of the active frontal sinus pneumatization or development that increases the risk of hematogenous spread of infection.1
Symptoms
Pott puffy tumor can present with a triad of symptoms including frontal headache (67–100 percent), forehead swelling (71–75 percent), and fever (59–63 percent) presenting within 1–28 days after the insult to the forehead.2 Despite the localized symptoms, PPT intracranial complications occur 38–72 percent of the time. Other common complications include epidural abscess, subdural empyema, brain abscess, meningitis, superior sagittal sinus thrombosis, dural venous thrombophlebitis, orbital complications/infections (71 percent of cases in a large cohort study).3
Indications for Testing
Key work-up includes imaging, such as a CT head without contrast, although if available, the diagnosis may be better characterized with an magnetic resonance imaging brain scan. The infection is treated with a prolonged course of broad-spectrum antibiotics that can penetrate the blood-brain barrier, often 4 to 8 weeks in duration, if treating underlying osteomyelitis. Early involvement of consultants, such as otolaryngology and neurosurgery physicians, is also key, as surgical intervention may be needed to drain infection and/or remove compromised bone.
Conclusion
In the case of this patient, he was transferred to the nearest children’s hospital where he underwent frontal sinus surgery. He was treated with IV antibiotics for nine days and was discharged home with oral antibiotics.
Dr. Gault just completed her emergency medicine residency at Baylor College of Medicine. She is passionate about advancing health equity and advocating for those underrepresented in medicine.
Dr. Pérez-Verdejo just completed her emergency medicine residency at Baylor College of Medicine. She is passionate about providing medical care to underserved and undocumented populations.
Dr. Adu-Gyamfi just completed her emergency medicine residency at Baylor College of Medicine. She is interested in health policy and passionate about advancing health equity and advocating for those underrepresented in medicine.
Dr. Gordon is currently in her medical education fellowship at Baylor Medical Center in Houston after completing her residency in emergency medicine at University of Houston at HCA Kingwood Emergency Medicine Residency Program.
References
- Sandoval JI, Hohman MH, De Jesus O. Pott Puffy Tumor. [Updated 2025 Feb 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560789/
- Klivitsky A, Erps A, Regev A, Ashkenazi-Hoffnung L, Pratt LT, Grisaru-Soen G. Pott‘s Puffy Tumor in Pediatric Patients: Case Series and Literature Review. Pediatr Infect Dis J. 2023;42(10):851-856. doi: 10.1097/INF.0000000000004026. Epub 2023 Jun 29. PMID: 37406183.
- Palabiyik FB, Yazici Z, Cetin B, Celebi S, Hacimustafaoglu M. Pott Puffy Tumor in Children: A Rare Emergency Clinical Entity. J Craniofac Surg. 2016;27(3):e313-6. doi: 10.1097/SCS.0000000000002573. PMID: 27100642.
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