Delayed Wound Infection Associated with Bone Wax in Lateral Skull Base Surgery

Background: Bone wax (Ethicon, Somerville, NJ) is a commonly used agent in neurotologic and skull base procedures. Its pliable nature makes it well suited for both hemostasis, especially for marrow-related bleeding, and obliteration of bony air cell tracts. The objective of this study was to review the first series to our knowledge of delayed wound infections associated with bone wax in lateral skull base surgery. We review the clinical presentations, imaging findings, microbiology, and outcomes.

Design: Retrospective case series.

Setting: Two tertiary academic referral hospitals.

Participants: Five patients underwent lateral skull base surgery for vestibular schwannoma or meningioma and presented with delayed wound infections. All patients underwent operative wound exploration as a part of their treatment.

Results: All patients presented with significantly delayed wound complications, from 4 months to 8 years after their original procedure. Purulence and inflammatory tissue surrounding bone wax was noted in each case, and fistula formation in some. Bacterial species cultured included pseudomonas aeruginosa, Proteus mirabilis, staphylococcus epidermidis, and Acremonium species (a fungus). Three of the four cases underwent some form of wound debridement or removal of hardware that was insufficient to clear the infection until a deeper nidus of bone wax was removed.

Conclusion: Although a valuable tool in lateral skull base surgery, bone wax should be used sparingly, and perhaps not to obstruct air cells. Residual accumulation of this material can be associated with foreign body reaction, fistula formation, and significantly delayed wound infections.