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ANORL-1065; No. of Pages 2 ARTICLE IN PRESS

European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2020) xxx–xxx

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Letter to the editor

Bone wax-induced recurrent frontal sinusitis after skull

base surgery

Dear Editor,
We would like to report three cases in which retained bone wax
after skull base surgery resulted in recalcitrant frontal sinusitis and
imaging changes concerning for mucocele. Each case was treated
with endoscopic frontal sinusotomy with meticulous removal of
bone wax, thereby resolving symptoms and imaging findings.
The first case is a 39-year-old male with traumatic bilat-
eral frontal sinus fracture treated with bilateral fat obliteration
developed recurrent left frontal sinusitis non-responsive to tra-
ditional endoscopic therapy. Computed tomography (CT) showed
left frontal sinus expansile opacification concerning for mucocele.
Endoscopic sinus surgery (ESS) was performed and a stenotic left
frontal sinus outflow tract with bone wax visible in the sinus was
discovered (Fig. 1A). After a left frontal sinusotomy, bone wax with
surrounding inflammation was removed (Fig. 1B). Six months post-
operatively, the patient remained asymptomatic.
Case two is a 66-year-old female who developed recurrent left
frontal sinusitis after excision of a left middle cranial fossa trigem-
inal schwannoma via pterional craniotomy. Magnetic resonance
imaging (MRI) displayed complete left frontal sinus opacification
with peripheral enhancement and restricted diffusion concerning
for mucocele. Left frontal sinusotomy was performed where bone
wax with surrounding polypoid changes and purulence were iden-
tified within the sinus (Fig. 2A). The bone wax was completely
removed and nine months postoperatively, the patient remained
asymptomatic (Fig. 2B).
Third case is a 16-year-old male with right frontal osteoma
was treated with frontal sinus cranialisation and pericranial flap
reconstruction. Intraoperatively, the left frontal sinus was inciden-
tally entered and bone wax placed for hemostasis. Postoperatively,
the patient developed recurrent left frontal sinusitis. MRI revealed
left frontal opacification with restricted diffusion concerning for
mucocele. Left frontal sinusotomy was performed where bone wax
with surrounding polypoid changes and purulence was seen. Bone
wax was completely removed and ten months postoperatively, the
patient remained asymptomatic.
Altogether, bone wax is a non-absorbable material made of
water-insoluble beeswax and vaseline. Its pliable nature makes it
ideal for hemostasis in the bony trabeculae; however, several stud-
ies have demonstrated detrimental effects of bone wax –reduced Fig. 1. Endoscopic view of the left frontal sinus outflow tract at A. the beginning
osteogenesis, production of chronic granulomatous inflammation, and B. conclusion of the case. A. demonstrates stenosis of the frontal sinus ostium
from scarring with bone wax distally. B. shows a patent ostium after a left frontal
and decreased bacterial clearance– making it an independent risk
sinusotomy.
factor for infection [1,2].
Given the unique location of the frontal sinus, it is imperative
to identify the correct etiology and properly treat disease to pre- so alternative etiologies should be considered [3]. There have only
vent intracranial and intraorbital complications. While recurrent been two case reports of bone wax-associated sinusitis [4,5]. Both
frontal sinusitis and mucoceles are theorised complications of skull cases were reported to be due to obstruction of sinus ostia. While
base surgeries, they do not occur to a significant extent in practice this certainly contributes, these three cases purport that it can also

https://doi.org/10.1016/j.anorl.2019.12.013
1879-7296/© 2020 Elsevier Masson SAS. All rights reserved.

Please cite this article in press as: Lovin BD, Clinger JD. Bone wax-induced recurrent frontal sinusitis after skull base surgery. European
Annals of Otorhinolaryngology, Head and Neck diseases (2020), https://doi.org/10.1016/j.anorl.2019.12.013
G Model
ANORL-1065; No. of Pages 2 ARTICLE IN PRESS
2 Letter to the editor / European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2020) xxx–xxx

act solely as a nidus for inflammation and infection with natural

flora given that all cases had patent ostia. Furthermore, imaging
of bone wax-induced inflammatory changes may mimic mucocele
formation as was seen in each case; however, bone wax itself is
hypointense on T1 and T2, which may allow it to be differentiated
if enough material is retained [5].
Retained bone wax should be considered by skull base sur-
geons as possible etiology for postoperative recalcitrant sinusitis
and imaging concerning for mucocele. Endoscopic approaches to
search for and meticulously remove the exogenous material will
produce sustained clinical improvement. Finally, judicious use of
bone wax is recommended, if placed in a sinus with patent ostium.

Disclosure of interest

The authors declare that they have no competing interest.

References

[1] Katz SE, Rootman J. Adverse effects of bone wax in surgery of the orbit. Ophthal
Plast Reconstr Surg 1996;12:121–6.
[2] Gibbs L, Kakis A, Weinstein P, Conte JE. Bone wax as a risk factor for surgical-
site infection following neurospinal surgery. Infect Control Hosp Epidemiol
2004;25:346–8.
[3] Bleier BS, Wang EW, Vandergrift WA, Schlosser RJ. Mucocele rate after endo-
scopic skull base reconstruction using vascularised pedicled flaps. Am J Rhinol
Allergy 2011;25:186–7.
[4] Kim KR, Cho SH, Jung JS, et al. A case of recurrent frontal sinusitis due to bone
wax. J Rhinol 2003;10:64–7.
[5] Kim SH, Park D, Lee J, Lee Y. Retained bone wax on CT at one year after dacry-
ocystorhinostomy: a case report. J Korean Soc Radiol 2015;73:190–4.

B.D. Lovin a,∗

J.D. Clinger b
a Department of Otolaryngology, Baylor College of

Medicine, 1, Baylor Plaza, Houston, TX, 77030, USA

b Department of Otolaryngology, Wake Forest School

of Medicine, Medical Centre Boulevard,

Winston-Salem, NC, 27157, USA

∗ Corresponding author at: Baylor College of

Medicine, 1, Baylor Plaza, NA-102 Houston, TX,

Fig. 2. Endoscopic view of the left frontal sinus outflow tract at A. the beginning 77030, USA.
and B. conclusion of the case. A. demonstrates mucosal polypoid inflammation and E-mail address: blovin@bcm.edu (B.D. Lovin)
purulence adjacent to bone wax in the frontal sinus. B. shows a patent ostium after
a left frontal sinusotomy.

Please cite this article in press as: Lovin BD, Clinger JD. Bone wax-induced recurrent frontal sinusitis after skull base surgery. European
Annals of Otorhinolaryngology, Head and Neck diseases (2020), https://doi.org/10.1016/j.anorl.2019.12.013