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Progressive Eyelid Swelling in a Middle-aged Man

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

An African American man in his 40s was referred for evaluation of a 3-week history of pain and swelling over his right orbit and upper eyelid. Worsening edema prompted his primary care physician to initiate a course of oral methylprednisolone and amoxicillin-clavulanic acid, which did not alleviate the symptoms. Because of persistent swelling, he was referred for further evaluation. The patient denied fevers, chills, purulent drainage, otalgia, or odynophagia. The patient had no history of frequent sinusitis, trauma, or exposure to chemicals, but he did note poor dentition.

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Pott’s puffy tumor (PPT) with supraorbital abscess

D. Perform an anterior orbitotomy with abscess drainage in conjunction with endoscopic sinus surgery

The differential diagnosis for a supraorbital mass includes malignant neoplasm, soft-tissue infections, frontal sinus mucocele, and various other lesions such as PPT, which is a rare clinical entity characterized by a subperiosteal abscess associated with osteomyelitis. It typically consists of osteomyelitis of the frontal bone, either directly or through hematologic spread.1

A rapidly growing mass unresponsive to conservative antibiotic therapy raised concern for a malignant neoplasm. However, because of the imaging finding of supraorbital abscess with communicating channels, an infectious process was more likely; therefore, an excisional biopsy would not be indicated (choice A). Antibiotic therapy failed to alleviate the symptoms in this patient. It would not be appropriate to administer intravenous (IV) antibiotics until the cause was better understood (choice B). Also, IV antibiotics alone would not be sufficient for treating this patient. Frontal sinus mucocele with orbital involvement can present similarly, with orbital displacement, proptosis, and diplopia and can be treated with removal of the frontal sinus cystic lining (choice C).2 However, the CT findings of this case did not show space-occupying lesions with eggshell bone erosion, which is characteristic for orbital mucocele.2

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Article Information

Corresponding Author: Jonathan Chao, MD, Beaumont Eye Institute, Beaumont Health, 3535 W 13 Mile Rd, #555, Royal Oak, MI 48073 (jonathan.chao@beaumont.org).

Published Online: November 12, 2020. doi:10.1001/jamaophthalmol.2020.4092

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Linton  S , Pearman  A , Joganathan  V , Karagama  Y .  Orbital abscess as a complication of Pott’s puffy tumour in an adolescent male.   BMJ Case Rep. 2019;12(7):229664. doi:10.1136/bcr-2019-229664 PubMedGoogle Scholar
2.
Wang  T-J , Liao  S-L , Jou  J-R , Lin  L L-K .  Clinical manifestations and management of orbital mucoceles: the role of ophthalmologists.   Jpn J Ophthalmol. 2005;49(3):239-245. doi:10.1007/s10384-004-0174-8 PubMedGoogle ScholarCrossref
3.
Hoxworth  JM , Glastonbury  CM .  Orbital and intracranial complications of acute sinusitis.   Neuroimaging Clin N Am. 2010;20(4):511-526. doi:10.1016/j.nic.2010.07.004 PubMedGoogle ScholarCrossref
4.
Nisa  L , Landis  BN , Giger  R .  Orbital involvement in Pott’s puffy tumor: a systematic review of published cases.   Am J Rhinol Allergy. 2012;26(2):e63-e70. doi:10.2500/ajra.2012.26.3746 PubMedGoogle ScholarCrossref
5.
Leong  SC .  Minimally invasive surgery for Pott’s puffy tumor: is it time for a paradigm shift in managing a 250-year-old problem?   Ann Otol Rhinol Laryngol. 2017;126(6):433-437. doi:10.1177/0003489417698497 PubMedGoogle ScholarCrossref
6.
Li  E , Distefano  A , Sohrab  M .  Necrotizing orbital cellulitis secondary to odontogenic Streptococcus constellatus.   Ophthalmic Plast Reconstr Surg. 2018;34(5):e160-e162. doi:10.1097/IOP.0000000000001185 PubMedGoogle ScholarCrossref
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