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J Am Coll Emerg Physicians Open
J Am Coll Emerg Physicians Open
10.1002/(ISSN)2688-1152
EMP2
Journal of the American College of Emergency Physicians Open
2688-1152
John Wiley and Sons Inc. Hoboken

10.1002/emp2.13256
EMP213256
Images in Emergency Medicine
Images in Emergency Medicine
Man with forehead swelling
WILLIAMS CHEN et al.
Williams Chen Madison C. MD 1
Passons Sally M. MD 1
Gullett John P. MD 1
Thompson Maxwell A. MD 1
Pigott David C. MD, RDMS 1
Burleson Samuel L. MD 1 slburleson@uabmc.edu

1 Department of Emergency Medicine University of Alabama at Birmingham Birmingham Alabama USA
* Correspondence
Samuel L. Burleson, MD, Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
Email: slburleson@uabmc.edu

10 9 2024
10 2024
5 5 10.1002/emp2.v5.5 e1325620 7 2024
23 7 2024
© 2024 The Author(s). Journal of the American College of Emergency Physicians Open published by Wiley Periodicals, Inc. on behalf of American College of Emergency Physicians.
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

source-schema-version-number2.0
cover-dateOctober 2024
details-of-publishers-convertorConverter:WILEY_ML3GV2_TO_JATSPMC version:6.4.8 mode:remove_FC converted:10.09.2024
Williams Chen MC , Passons SM , Gullett JP , Thompson MA , Pigott DC , Burleson SL . Man with forehead swelling. JACEP Open. 2024;5 :e13256. 10.1002/emp2.13256

Meetings: 2024 Poster Session, Emerald Coast Conference, Sandestin, FL, USA.
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pmc1 PATIENT PRESENTATION

A 60‐year‐old male presented to the emergency department with the complaint of “sinus infection and facial swelling.” The patient endorsed worsening symptoms for 1 month including nasal congestion, bloody nasal drainage, facial swelling and pain, and new onset diplopia. Physical examination was notable for forehead swelling extending to the periorbital area bilaterally (Figure 1). Point‐of‐care ultrasound was performed (Figures 2 and 3) and identified a heterogeneous highly vascular soft tissue mass with associated defect of the frontal bone. Computed tomography of the head and maxillofacial structures was obtained (Figure 4), confirming the diagnosis of a large anterior soft tissue mass with destruction of the frontal bone and mass effect on the orbits.

FIGURE 1 Photograph demonstrating forehead swelling with bilateral periorbital mass effect noted.

FIGURE 2 Point‐of‐care ultrasound view of patient's anterior forehead demonstrating discontinuity and erosion of frontal bone (arrowhead) with protrusion of heterogeneous soft tissue mass (asterisk).

FIGURE 3 Point‐of‐care power doppler ultrasound view of patient's forehead demonstrating extensive vascularity within the mass.

FIGURE 4 Computed tomography in axial plane with view of orbits and cribriform demonstrating large mass centered at the cribriform plate (asterisk) involving the frontal and ethmoid sinuses as well as left nasal cavity with extensive mass effect with lateral displacement of the orbits (arrows).

2 DIAGNOSIS: SINONASAL SQUAMOUS CELL CARCINOMA

The patient underwent endoscopic biopsy, demonstrating squamous cell carcinoma originating from the skull base. In patients presenting with forehead swelling, point‐of‐care ultrasound (POCUS) provides a rapid imaging modality for superficial soft tissue masses. 1 , 2 Given the broad differential for this presentation, POCUS can facilitate the evaluation of skin and soft tissue infections, soft tissue, and bony or vascular pathology. Importantly, the use of Doppler ultrasound can prevent inadvertent incision of occult vascular structures. 3 POCUS has aided the diagnosis of Pott's puffy tumor, a rare disorder which may present with forehead swelling due to an underlying abscess associated with frontal bone osteomyelitis. 4 In evaluation of forehead masses, ultrasound can expedite further investigation by providing characterization of substance, vascularity, and compressibility. 5 POCUS examination in this patient rapidly facilitated appropriate additional imaging, consultation and diagnosis, and the avoidance of harmful bedside procedures.

CONFLICT OF INTEREST STATEMENT

The authors declare conflicts of interest.
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REFERENCES

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