Management of pott's puffy tumor: a Delphi-method international clinical consensus statement

Nicolien van der Poel^{1

2}, Gopi Shah³, Nikolaus Wolter⁴, Christos Georgalas⁵, Anneclaire Vroegop^{1

2}, Vincent Couloigner⁶, Francois Simon^{6

7}, Amanda L Stapleton⁸, Dana Crosby⁹, Uma Ramaswamy¹⁰, Patrick Walz¹¹, Randa Al-Barazi¹², Peter-John Wormald¹³, Enrique Ortiz¹⁴, Perla Villamor¹⁵, Jin-Young Min¹⁶, Alvaro Pacheco¹⁷, Cristobal Langdon¹⁸, Paresh Naik¹⁹, Shazia Peer²⁰, Rania Mehanna²¹, John R Craig²², Alberto Maria Saibene²³

Affiliations

¹ Department of Otorhinolaryngology, Antwerp University Hospital, Antwerp, Belgium.
² Faculty of Medicine and Translational Neurosciences, University of Antwerp, Antwerp, Belgium.
³ Pediatric otolaryngologist at ENT Surgery Solutions, Evansville, IN, USA.
⁴ Department of Otolaryngology - Head & Neck Surgery, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
⁵ Department of Head, Neck and Skull Base Surgery, Hygeia Hospital, Athens, Greece.
⁶ Department of Pediatric Otolaryngology, AP-HP, Hôpital Necker Enfants Malades, Paris, France.
⁷ Université Paris Cité, Paris, F-75006, France.
⁸ Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA.
⁹ Department of Otolaryngology Head and Neck Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA.
¹⁰ Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, USA.
¹¹ Department of Pediatric Otolaryngology-Head and Neck Surgery, Nationwide Children's Hospital, Columbus, OH, USA.
¹² Department of Otolaryngology and Head and Neck Surgery, American University of Beirut Medical Center, Beirut, Lebanon.
¹³ Department of Surgery-Otorhinolaryngology Head and Neck Surgery, Central Adelaide Local Health Network, University of Adelaide, Adelaide, SA, Australia.
¹⁴ Antiguo Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico.
¹⁵ Ear, Nose and Throat Department, American Hospital, Dubai, United Arab Emirates.
¹⁶ Department of Otorhinolaryngology-Head & Neck Surgery, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Republic of Korea.
¹⁷ Clínica Universidad de Los Andes, Santiago, Chile.
¹⁸ Department of Pediatric Otorhinolaryngology, Hospital Sant Joan de Deu, Barcelona, Spain.
¹⁹ Department of Otorhinolaryngology, Jaslok Hospital & Research Centre, Mumbai, India.
²⁰ Department of Otolaryngology, University of Cape Town, Cape Town, South Africa.
²¹ Department of Otolaryngology, Our Lady's Hospital for Sick Children, Crumlin, Dublin, Ireland.
²² Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health, Detroit, MI, USA.
²³ Otolaryngology Unit, Department of Health Sciences, Santi Paolo e Carlo Hospital, Università Degli Studi di Milano, Milan, Italy. alberto.saibene@unimi.it.

PMID: 40782155
PMCID: PMC12423165
DOI: 10.1007/s00405-025-09589-1

Management of pott's puffy tumor: a Delphi-method international clinical consensus statement

Nicolien van der Poel et al. Eur Arch Otorhinolaryngol. 2025 Sep.

. 2025 Sep;282(9):4669-4680.

doi: 10.1007/s00405-025-09589-1. Epub 2025 Aug 9.

Authors

Affiliations

¹ Department of Otorhinolaryngology, Antwerp University Hospital, Antwerp, Belgium.
² Faculty of Medicine and Translational Neurosciences, University of Antwerp, Antwerp, Belgium.
³ Pediatric otolaryngologist at ENT Surgery Solutions, Evansville, IN, USA.
⁴ Department of Otolaryngology - Head & Neck Surgery, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
⁵ Department of Head, Neck and Skull Base Surgery, Hygeia Hospital, Athens, Greece.
⁶ Department of Pediatric Otolaryngology, AP-HP, Hôpital Necker Enfants Malades, Paris, France.
⁷ Université Paris Cité, Paris, F-75006, France.
⁸ Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA.
⁹ Department of Otolaryngology Head and Neck Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA.
¹⁰ Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh Medical Center, Pittsburgh, USA.
¹¹ Department of Pediatric Otolaryngology-Head and Neck Surgery, Nationwide Children's Hospital, Columbus, OH, USA.
¹² Department of Otolaryngology and Head and Neck Surgery, American University of Beirut Medical Center, Beirut, Lebanon.
¹³ Department of Surgery-Otorhinolaryngology Head and Neck Surgery, Central Adelaide Local Health Network, University of Adelaide, Adelaide, SA, Australia.
¹⁴ Antiguo Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico.
¹⁵ Ear, Nose and Throat Department, American Hospital, Dubai, United Arab Emirates.
¹⁶ Department of Otorhinolaryngology-Head & Neck Surgery, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Republic of Korea.
¹⁷ Clínica Universidad de Los Andes, Santiago, Chile.
¹⁸ Department of Pediatric Otorhinolaryngology, Hospital Sant Joan de Deu, Barcelona, Spain.
¹⁹ Department of Otorhinolaryngology, Jaslok Hospital & Research Centre, Mumbai, India.
²⁰ Department of Otolaryngology, University of Cape Town, Cape Town, South Africa.
²¹ Department of Otolaryngology, Our Lady's Hospital for Sick Children, Crumlin, Dublin, Ireland.
²² Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health, Detroit, MI, USA.
²³ Otolaryngology Unit, Department of Health Sciences, Santi Paolo e Carlo Hospital, Università Degli Studi di Milano, Milan, Italy. alberto.saibene@unimi.it.

PMID: 40782155
PMCID: PMC12423165
DOI: 10.1007/s00405-025-09589-1

Abstract

Purpose: Pott's puffy tumor (PPT) is a rare and complex condition that requires a comprehensive diagnostic approach and multi-faceted treatment strategy. It is associated with a significant risk of intracranial complications. The purpose of this clinical consensus statement (CCS) is to systematically assess diagnostic and therapeutic approaches of patients with PPT, using the best available evidence and expertise of the panel. The results and recommendations are intended to support clinicians in making informed decisions when managing patients with PPT and to standardize diagnostic, antibiotic, and surgical management across institutions. This consensus also aimed to provide a basis for a subsequent international prospective registry to inform data-driven care.

Methods: A literature review was performed via PubMed, and an international panel of 23 experts judged 33 statements in two rounds using a modified Delphi method survey to establish expert recommendations on the diagnostic considerations, medical and surgical management, and postoperative considerations. Strong consensus was defined by a mean score of ≥ 8.00 with no outliers, and consensus by a mean score of ≥ 7.00 with no more than 1 outlier.

Results: A strong consensus was reached on important aspects of the diagnosis and treatment of patients with PPT. Most pivotal are the importance of urgent imaging, imaging of the brain with a preference of MRI, the importance of broad spectrum intravenous antibiotic treatment, and the goal of surgery - resolution of the periosteal abscess and clearance of the frontal sinus drainage pathway - which can be established in various ways and is case and surgeon dependent.

Conclusion: In patients with PPT, a high index of suspicion of intracranial complications is important to prevent any delay in treatment initiation. The recommendations formulated in this international consensus statement aim to improve the diagnosis and care for patients with PPT and to address gaps and uncertainties in current guidelines. Items that did not reach consensus may serve as areas for further research.

Keywords: Acute sinusitis; Clinical guideline; Delphi consensus; Expert consensus; Intracranial abscess; Pediatric otolaryngology; Pott’s puffy tumor.

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Conflict of interest statement

Declarations. Competing interests: The authors have no potential conflicts of interest to report pertaining to this study. The authors received no funding for this article or related research. Disclosures: The authors have no potential conflicts of interest to report pertaining to this study. The authors received no funding for this article or related research. Ethical approval: was not required because the study did not involve any patient-related data.

Figures

**Fig. 1**
World map reporting the geographic distribution of the panelists

**Fig. 2**
Flowchart and results of the Delphi process

See this image and copyright information in PMC

References

1. Nallani R, Wichova H, McAroy JL, Chiu AG, Villwock JA (2021) Incidence of odontogenic disease in patients with Pott’s puffy tumor. J Oral Maxillofac Surg 79:389–397. 10.1016/j.joms.2020.08.001 - PubMed
1. Klivitsky A, Erps A, Regev A, Ashkenazi-Hoffnung L, Pratt LT, Grisaru-Soen G (2023) Pott’s puffy tumor in pediatric patients: case series and literature review. Pediatr Infect Dis J 42:851–856. 10.1097/INF.0000000000004026 - PubMed
1. Rohde RL, North LM, Murray M, Khalili S, Poetker DM (2022) Pott’s puffy tumor: a comprehensive review of the literature. Am J Otolaryngol 43:103529. 10.1016/j.amjoto.2022.103529 - PubMed
1. Fokkens WJ, Lund VJ, Hopkins C et al (2020) European position paper on rhinosinusitis and nasal polyps 2020. Rhinology 1–464. 10.4193/Rhin20.600 - PubMed
1. Smiljkovic M, Tat J, Richardson SE et al (2024) A 20-year study of intracranial pyogenic complications of sinusitis in children. Pediatr Infect Dis J 43:91–96. 10.1097/INF.0000000000004140 - PubMed

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Management of pott's puffy tumor: a Delphi-method international clinical consensus statement

Affiliations

Management of pott's puffy tumor: a Delphi-method international clinical consensus statement

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

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MeSH terms

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LinkOut - more resources

Full Text Sources