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OBJECTIVE: Bone wax is a flexible hemostatic agent commonly used for surgery in the posterior cranial fossa to control bleeding from the mastoid emissary vein. A large amount of bone wax can migrate into the sigmoid sinus through the mastoid emissary canal (MEC). We aimed to identify clinical factors related to intraoperative bone wax migration through the MEC during microvascular decompression (MVD) surgery, which may result in sigmoid sinus thrombosis.
METHODS: We retrospectively collected the clinical data of patients with trigeminal neuralgia, hemifacial spasm, or trigeminal neuralgia accompanied by painful tic convulsif who underwent MVD. Basic information and the residual width and length (from the bone surface to the sigmoid sinus) of the MEC on computed tomography images were collected. We compared the collected clinical data between 2 groups of cases with and without intraoperative bone wax migration in the sigmoid sinus.
RESULTS: Fifty-four cases with intraoperative bone wax migration and 187 patients without migration were enrolled. The t -test revealed significant differences in the width and length of the MEC ( P = .013 and P = .003, respectively). These variables were identified as significant factors in predicting intraoperative bone wax migration using multivariate logistic regression analysis.
CONCLUSIONS: The large size of the MEC may be related to intraoperative bone wax migration into the sigmoid sinus in MVD. Neurosurgeons should be aware of these risks. Bone wax should be applied appropriately and hemostasis should be considered to control bleeding from the mastoid emissary vein in patients with a large MEC.

The purposes of this article are to report the clinical case of a patient who exhibited a foreign body reaction associated with the use of bone wax after extraction of an impacted third molar and to present an integrative literature review addressing the possible influences of this hemostatic agent on bone healing. A 26-year-old woman who underwent the extraction of her mandibular right third molar developed intense alveolar bleeding during surgery, requiring the use of bone wax. In the 2-month postoperative period, the patient presented with intraoral edema and discharge of a purulent secretion via the alveolar route. After cone beam computed tomographic images revealed increased hyperdensity inside the alveolus, alveolar curettage was performed and the material that was obtained was submitted to histopathologic examination. The results of the histopathologic analysis proved conclusive for an inflammatory foreign body reaction associated with exogenous material. A search of the PubMed, SciELO, and LILACS databases identified 22 studies that evaluated the influence of this hemostatic agent on bone healing, and an integrative review involving 367 animals and 75 humans was compiled. Bone wax is a nonresorbable material capable of negatively influencing bone healing. It is suggested that the product be used cautiously in amounts that are just enough to promote the sealing of the bone channels.

Background: Cochlear implantation is a well-established treatment for severe-to-profound sensorineural hearing loss. While bone wax is used commonly during mastoidectomy and other bony surgeries as a hemostatic agent, there have been reports of bone wax triggering foreign body reactions, months to years after surgery. This report describes the first known foreign body reaction to bone wax used in cochlear implantation surgery. Case Presentation: A 6-year-old male presented with an unusual post-auricular inflammation two years after cochlear implantation. Extended treatment with oral and intravenous antibiotics failed to resolve the presumed infection. Upon exploration of the mastoid cavity, fragments of bone wax were discovered within the granulation tissue. Excision of bone wax fragments and local flap reconstruction resulted in complete resolution of the inflammatory process. Conclusions: Bone wax has been implicated in foreign body reactions in many different surgical specialties. This is the first reported case of an adverse reaction to bone wax after cochlear implantation. Clinically, the bone wax reaction was misinterpreted as an implant infection, which resulted in extended antibiotic use and delay of appropriate treatment. As a result, bone wax should be used judiciously during mastoidectomy, and particularly in the area of the electrode and soft tissue closure.

BACKGROUND: Bone wax is the most widely used hemostatic bone sealant because of its availability, ease of use, immediate action, and minimal adverse effects. Several complications have been reported to be associated with the use of bone wax, such as infection, osteohypertrophy, pain, granuloma formation, allergic reaction, and thrombosis. Here, we present a rare complication, namely, bone wax migration, which developed after a craniotomy on a patient who had a frontal sinus abnormality.
METHODS: A 51-year-old woman complained of pain and swelling in her left eye accompanied by difficulty opening the left eyelid after undergoing a craniotomy. An examination revealed left eye proptosis with ptosis, eyelid swelling, and increases in intraorbital pressure and intraocular pressure (IOP). According to a CT and an MRI of the orbit, we found that the intraoperative bone wax had migrated to the orbit, thereby causing compression. We also found that the basal frontal sinus of the patient was congenitally defective, which may have induced the migration of the bone wax. Given that the patient recently underwent a craniotomy and given the risks associated with orbital surgery, she refused to undergo a surgery to remove the bone wax. Thus, the patient was administered mannitol intravenously daily, accompanied by topical Timolol, to reduce the intraorbital pressure and IOP. This treatment led to a gradual decrease in IOP and intraorbital pressure, and these parameters remained stable after treatment ended. During the 6-month follow-up, the best corrected visual acuity improved, and ptosis and restricted eye movements also improved significantly.
CONCLUSIONS: We report a case of bone wax migration that developed after a craniotomy on a patient who had a congenital defect in the basal frontal sinus. Extra caution should be taken when using bone wax, and a comprehensive understanding of the patient\'s intracranial anatomy is important for decreasing the incidence of bone wax migration. Additionally, when a patient presents with symptoms of ocular compression, bone wax migration should be considered in addition to typical radiological changes.

Bone wax is an effective hemostatic agent that generally is considered safe. However, because it is nonabsorbable, significant complications can occur. We present the first two reported cases of delayed migration and extrusion of bone wax through postauricular wounds due to foreign body reaction and granuloma formation following mastoid surgery. We also present a literature review of complications associated with intraoperative bone wax use and discuss alternative hemostatic agents. Laryngoscope, 128:369-372, 2018.

BACKGROUND: Vertex epidural hematoma (VEH) is an uncommon presentation of extra-axial hematomas. It can represent a surgical dilemma regarding when and how to operate, particularly considering the potential implication of the superior sagittal sinus (SSS).
OBJECTIVE: Here, we illustrate the surgical technique for VEH as well as a review of the existing literature.
METHODS: A 60-year-old man sustained a ground-level fall resulting in complete diastasis of the sagittal suture with underlying large VEH causing significant mass effect on the SSS and bihemispheric convexities. Twenty-four hours later, the patient deteriorated, with decreased level of alertness and worsening asymmetric paresis on his lower extremities. He subsequently underwent surgical evacuation of the hematoma, decompression of the SSS, and fracture repair. A modified bicoronal approach, with bilateral parasagittal craniotomies, was performed. A central island of bone was left intact to spare the diastatic fracture from the craniotomies. This was done to ensure a stable anchor point for tacking-up the underlying displaced dura and SSS. The central bone prevents extensive bleeding from the diastatic fracture and eliminates the risk of further blood reaccumulation and tearing of a possible injured sinus during bone flap elevation.
RESULTS: The technique performed allowed us to evacuate completely the hematoma while preserving the SSS and repairing the sagittal suture to avoid further bleeding. Complete neurologic recovery of the patient occurred after VEH evacuation.
CONCLUSIONS: Because of its rare nature, VEH represents a surgical challenge. Because neurosurgeons encounter this condition relatively infrequently, literature regarding the medical and surgical management of this entity is warranted.

Enzymatic digestion of lipid drug carriers is very important. Commonly, pancreatin induced formation of fatty acids is monitored by the pH-stat method, which provides a fast, but unspecific readout. However, according to the literature, the pKa values of long chain fatty acids are strongly dependent on the local environment and might vary between 4.2 and 10.15. The high pKa values would lead to an incomplete detection of the lipid digestion and false results. In order to investigate these issues in more detail, we produced cetyl palmitate solid lipid nanoparticles (CP-SLN) stabilized with poloxamer 188 or polysorbate 80. The digestion of CP-SLN was investigated by two different and independent readouts. A HPTLC assay was used in addition to the pH-stat method (with or without back titration). An incomplete digestion of CP-SLN was observed with all methods. Partial digestion of polysorbate 80 contributed to the formation of fatty acids. Depending on the investigated system and the experimental conditions (FaSSIF or FeSSIF) the results of both readout methods were comparable or not. For example, in FeSSIF conditions, the values detected by HPTLC were roughly twice as high as the pH-stat results. Our findings on solid lipids agree with data from Helbig et al. on lipid emulsions, where a gas chromatography method detected much higher values than the pH-stat assay (Food Hydrocoll. 28 (2012) 10-19). The results of our pH-stat experiments with back titration at different pH values showed increased values for fatty acids from pH 7.5 to pH 10. The values obtained by back titration at high pH values (pH 9 or higher) did exceed the digestion values measured by HPTLC. Therefore, we conclude that the pH-stat method might give the same results as more specific reference methods, but it might also both under- (without back titration) or overestimate (with back titration) the enzymatic digestion of lipid drug delivery systems. A further outcome of our study was the proof that lipase is the main enzyme involved in the digestion of the solid wax cetyl palmitate, because CP-SLN loaded with the inhibitor orlistat were not digestible and gave similar values as the corresponding control samples. In summary, our experimental results confirm the theoretical considerations (based on published pKa values) that the pH-stat method will not detect all fatty acids quantitatively. The very strong impact of the local environment on the pKa value of long chain fatty acids is a serious limitation and might lead to misleading interpretations.

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