Rathke's cleft cyst presenting as sphenoid sinusitis

Use of Tympanostomy T-Tube for Endoscopic Endonasal Marsupialization of Small Rathke's Cleft Cysts: A Case Series

Objectives  This article describes a novel technique implementing the use of a tympanostomy t-tube to provide long-term marsupialization of small Rathke's cleft cysts (RCCs). Design  A retrospective review of electronic medical records was performed to collect demographic and clinical data on a series of four patients. Setting  Academic medical center. Participants  Four female patients (mean age of 34 years) underwent transsphenoidal endoscopic endonasal surgery for RCC. All four patients presented with headaches. Mean cyst size was 7 mm. Two of the four surgeries were revisions for RCC recurrence. Main Outcome Measures  Symptom resolution after surgery, duration of follow-up, and feasibility of the proposed technique. Results  Tympanostomy t-tube was used to marsupialize small RCCs (< 10 mm) for four patients. Three patients remained symptom-free with endoscopy and imaging showing patent t-tubes at 21 months' (range 20-24 months) follow-up. One patient experienced severe migraines immediately after surgery. Migraines were relieved after t-tube was removed 6 weeks after surgery. Conclusion  Tympanostomy t-tubes placed via an endoscopic endonasal approach can provide long-term marsupialization for small RCCs.

Rathke's cleft cyst recurrence after transsphenoidal surgery: a meta-analysis of 1151 cases

Rathke's cleft cysts (RCC) arise from the development of the Rathke's cleft pouch. These commonly occurring cysts are typically asymptomatic, but sometimes present with headaches, endocrine dysfunction, and visual loss. Recurrence is common after either drainage or surgical removal. The purpose of this study was to review published outcomes for RCC management, and determine whether specific factors, including patient demographics, cyst pathology, radiologic parameters, or surgical techniques predispose to their recurrence. A systematic review of studies for RCC from 1990 to 2012 was conducted. Patients were identified using a Medline/PubMed search, and from the bibliographies of relevant articles obtained from the primary search. Relevant studies reporting recurrence rate were identified, and data were extracted regarding patient demographics, presenting symptoms, cyst characteristics, surgical treatment, and outcomes. A meta-analysis for recurrence rates was also performed. Twenty-eight journal articles comprising a total of 1151 RCC revealed an average follow-up of 38 months (range 16-79 months). In the studies reviewed, there was a relatively equal distribution of treatment approaches, with 35% subtotal resection, 33% gross total resection, and 32% complete drainage with wall biopsy. The microsurgical transsphenoidal approach was found to have a higher recurrence rate (14% versus 8%) and new endocrine dysfunction rate (25% versus 10%) compared to the endoscopic approach. The data demonstrates a notable overall recurrence rate for RCC (12.5%). However, there appears to be no conclusive evidence that more aggressive resection of the cyst wall results in lower rates of recurrence.

Management of Rathke's cleft cysts

BACKGROUND

Incidental diagnosis of Rathke's cleft cysts (RCCs) has increased due to the improvements in imaging techniques; however, symptomatic cases are rare and accurate preoperative diagnosis can be difficult.

METHODS

Files and magnetic resonance imaging (MRI) of 10 surgically treated patients with RCC and 8 conservatively managed cases with a suspected diagnosis were reviewed retrospectively. Clinical, radiological, and histological features as well as intraoperative findings were scrutinized.

RESULTS

In the surgical group, headache was present in 4 patients, hormonal abnormality in 4, visual deficits in 3, and otolaryngological symptoms in 2. Two of the nonsurgical cases had hyperprolactinemia, and the remaining were asymptomatic. The cyst had suprasellar extension (SSE) in 9 patients and was entirely suprasellar in 1 in the surgical group. It was purely intrasellar in 6 nonsurgical cases and had SSE in 2. The cyst content showed hyperintense MRI signal in the majority of T1 and T2 images in both groups. Transsphenoidal surgery was performed in 8 and transcranial surgery in 2 patients. Squamous metaplasia and inflammation was present in 3 cases each. Initial hormonal deficiencies did not improve postoperatively and new deficits were observed in 2 cases. There was no recurrence with an average follow-up of 32 months.

CONCLUSIONS

Rathke's cleft cysts is a rare pathology with a wide spectrum of clinical and radiological features. Reactive inflammation of the normal pituitary gland may have a role in the pathogenesis of hormonal deficiency, in addition to compression. Preoperative recognition of the anteriorly displaced normal residual gland may be important in avoiding postoperative hormonal deficiency after transsphenoidal approach.