puff the magic dragon - acp online
TRANSCRIPT
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PUFF THE MAGIC DRAGON
AN UNUSUAL CASE OF A PUFFY FACE
MA ACP Annual Scientific MeetingGurbir Gill, M.D., PGY-3 (Associate)
George M. Abraham, MD, MPH, FACPDepartment of Medicine, Saint Vincent Hospital, Worcester, MA
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WAIT, MAGIC DRAGONS?
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PRESENTATION
53 year old female from Dominican RepublicReported a lump, left side of forehead, a week before presentation
Rapidly increased in size, pain and tenderness
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REVIEW OF SYSTEMSConstitutional: No fever, night sweats, sleep abnormalities, fatigue, malaise or lethargy.
Head and neck: Forehead lump, no trauma or bites, headache or neck swelling.
Vision: No vision loss, eye pain, double vision, redness, discharge.
ENT: No hearing loss, nasal pain or discharge, dysphagia, ulcers.
Gastrointestinal: No nausea, vomiting, diarrhea, abdominal pain, blood in stools or dark-colored stools.
Chest/CVS: No chest pain, wheezing, shortness of breath, anxiety, palpitations, orthopnea, PND or foot swelling.
Musculoskeletal: No muscle ache, joint pain, stiffness, swelling or limitation of mobility.
Neurological: No loss of consciousness, fainting, confusion, memory loss, fatigue, malaise or seizures.
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PAST MEDICAL HISTORY
Chronic sinusitis for many years Migraine headachesLeft trapezius abscess (drained in ED)Negative PPD few years ago
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SOCIAL HISTORY
Immigrated from Dominican Republic a few years ago.Lives at home with her family. Occasional alcohol use. No smoking or drug use.Independent in her daily activities.
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HOME MEDICATIONS
MultivitaminsAcetaminophen/Butalbital/Caffeine PRN
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PRESENTING LABS
9.714.0
42.3291
146
3.5
105
26
8
0.5
103
10.1
INR1.0ESR16CRP19.86UAclear
Neutrophils75%Lymphocytes21%Nobands
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PHYSICAL EXAMINATION
Vitals: 98.4ºF, HR 73, RR 18, BP 164/96mm/hg, 95% RA, No acute distress
Inspection: 3cm x 3cm smooth round mass with smooth borders. No skin break, ulcer or discoloration.
Palpation: Puffy, smooth, non pulsatile, minimally mobile mass with mild to moderate tenderness, no warmth.
Eyes: No eyelid swelling, limitation of EOMs or visual field loss. Normal pupillary reflexes.
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PHYSICAL EXAMINATION
Head: Lump as described, normocephalic, atraumatic, No cervical LNE.
Cranial nerves: grossly within normal limits.
Chest: clear to auscultation bilaterally. No added sounds.
CVS: S1, S2 is normal. No murmurs, rubs or gallops.
Abdomen: soft, nontender, nondistended. No organomegaly, normal bowel sounds.
MS: There is no obvious joint deformity, limitation or swelling.
Neuro: No motor/sensory deficits, reflexes brisk.
Extremities: No pedal edema, cyanosis or varicosities.
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http://uwmsk.org/sinusanatomy2/Frontal-Normal.html
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NEXT MORNING
Sudden onset puffiness and discomfort of the forehead, eyelids and cheeks.
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SURGERIES PERFORMED
1. Bifrontal craniotomy with removal of intracranial mass.2. Obliteration and cranialization of frontal
sinuses.
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Frontalbone
Scalpflap(reflectedanteriorly)
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Frontalboneflap:Removal
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Frontalboneflap
Erosionthroughtheposteriortable
Intracranialcavity
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Frontalboneflap:innersurface
FrontalSinus:exposed
Materialremovedfromfrontalsinus
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Postcranialization offrontalsinuses
Frontalboneflap:innersurface
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Frontalboneflap:Outersurface
Metalplatecoveringthedefectintheanteriortableofthefrontalsinus
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Frontalboneflap:Re-attached
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POST SURGICAL COURSE
Patient responded well post surgery. No complications.
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POST SURGICAL COURSE
Mass biopsy: Chronic inflammatory changes.
No malignant cells.
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POST SURGICAL COURSE
CultureMicroaerophilic streptococciHaemophilus parainfluenzae
Antibiotic therapy6 week IV ceftriaxone
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POTT’S PUFFY TUMOR
Misnomer (not a tumor)
Infective complication of frontal sinusitis
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POTT’S PUFFY TUMOR
Obstructed frontal sinusitis erodes through the anterior wall of the sinus to form subperiosteal or subgaleal collection
Creates a puffy lump in the forehead
http://www.aafp.org/afp/2008/1015/p953.html
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PUFF THE MAGIC DRAGON
AN UNUSUAL CASE OF A PUFFY FACE
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THANK YOU
Thank George M. Abraham, MD, MPH, FACP
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QUESTIONS?