Page 62 - Revista Portuguesa - SPORL - Vol 62. Nº2

we start with a broad-spectrum antibiotic like the treatment of Pott's puffy tumor should
third generation cephalosporin, which can
penetrate the blood-brain barrier effectively.
The supraciliary incision allows easy and safe
access to drain the PPT without big cosmetic
concerns related to the scar . Performing
11
endoscopic sinus surgery in cases of PPT
will not always be necessary and should be
determined on a case-by-case basis. Factors
such as the severity of the condition, presence
of intracranial complications, response to
conservative treatments, and individual
patient considerations should be considered
when deciding on the appropriate treatment.
In some cases, surgical intervention may
be warranted to address underlying sinus
pathology contributing to the condition or to
drain abscesses effectively, however, there are
also reports in which the response has been
favorable with isolated antibiotic treatment .
12
Traditionally, the surgical management of PPT
typically required an external approach. This
method allowed for clear visualization of frontal
sinus lesions but posed the risk of undesirable
facial scarring. Recent advancements in
technology and surgical techniques have
expanded the use of endoscopic approaches,
even extending to skull base and orbital
pathology. With growing expertise and
refined techniques, the success rates of
endoscopic intranasal frontal sinusotomy
now exceed those of external approaches .
13
The long-term outcomes of endonasal
treatment in patients with Pott's puffy tumor
demonstrate promising results. Studies have
shown sustained resolution of symptoms
and favorable disease control in most cases
following endonasal surgical intervention.
Specifically, the endoscopic approach offers
several advantages, including improved
visualization of affected areas, thorough
removal of infected tissue, and effective
drainage of sinus contents, which contribute
to reduced rates of recurrence. Additionally,
the endonasal approach minimizes the risk
of cosmetic disfigurement and facial scarring
associated with external surgical techniques.
The decision between Draf I and Draf III in
172 Revista Portuguesa de Otorrinolaringologia - Cirurgia de Cabeça e Pescoço
be individualized based on the specific
characteristics of the patient's disease and
their overall health status. While Draf I offers a
less invasive option with quicker recovery, Draf
III provides more extensive disease clearance
and may be necessary for cases with significant
disease involvement. Careful consideration
of the risks and benefits of each approach is
essential to optimize patient outcomes.
Longitudinal follow-up studies have reported
high patient satisfaction rates and low
incidence of complications, highlighting
the efficacy and safety of endonasal surgery
in the management of PPT. Moreover,
advancements in surgical technology
and techniques continue to enhance the
outcomes of endonasal procedures, further
solidifying its role as a preferred treatment
modality for this condition. However, in case of
failure or difficulty accessing the frontal sinus
endoscopically, external access must still be
considered as an alternative in the treatment
of PPT . In our case, given that the patient
13
had presented an unfavorable evolution
despite conservative treatment, with an
increase in the size of the frontal abscess and
intracranial extension, a surgical approach
was decided combining both endonasal
and external approaches, associated with
intravenous antibiotic treatment. Antibiotic
treatment should be prolonged for at least 6
weeks and a common combination is a third-
generation cephalosporin, metronidazole, and
vancomycin, that could be modified based on
culture results. Cultures from patients with PPT
very often reveal polymicrobial involvement
and a significant number of anaerobic when
intracranial complications are encountered.
In our case Eikenella corrodens was isolated,
that is a Gram-negative facultative anaerobic
bacillus, commensal of the human mouth
and upper respiratory tract, capable of acting
as an opportunistic pathogen and causing
abscesses in several anatomical sites 14,15 .