Preventing Restenosis of Marsupialized Rathke Cleft Cysts Using a Nasoseptal Flap Lining

Abstract

Objectives Rathke cleft cysts (RCCs) are rare, benign lesions formed from remnants of Rathke pouch during embryologic development. However, following marsupialization, maintaining tract patency remains a challenge. Several techniques for decreasing stenosis have been described, including free mucosal grafting, silastic spacing, and using steroid‐eluting stents. Nasoseptal flaps (NSFs) have a reliable vascular supply and are widely utilized in skull base reconstruction. We present a novel technique to maintain patency of the marsupialized RCC cavity by lining it with an NSF to promote long‐term drainage and re‐epithelialization of the RCC cavity. Methods Retrospective chart review of all patients who underwent surgery for symptomatic RCCs. These patients underwent endoscopic endonasal surgery between February 3, 2016, and June 12, 2018, with marsupialization followed by circumferential NSF lining. Primary outcomes include symptomatic control, surgical complications, and RCC cavity patency. Results Seven patients underwent RCC marsupialization with no intraoperative cerebrospinal fluid leak, followed by circumferential lining of the marsupialized cavity with an NSF. In each case, no cyst re‐accumulation or recurrent symptoms were noted, and the NSF lining provided long‐term patency of the tract in all cases to a mean of 6.7 ± 10.1 months of follow‐up, including one patient with sustained patency at 29 months follow‐up. Conclusion Utilization of the NSF to “stent open” the RCC cavity following marsupialization is a safe and effective means to prevent restenosis. Advantages include sustained patency of RCC cavity for complete drainage and a dependable vascular supply. Level of Evidence 4 Laryngoscope, 129:2258–2261, 2019

Spinal dural arteriovenous fistula rupture after Rathke’s cleft cyst endoscopic resection: Case report and literature review

“…Surgical intervention is indicated for treatment of headaches, visual disturbances, or endocrinopathies. [ 12 ] Reliable surgical approaches have been described for the treatment of RCCs. The current standard is an endonasal, commonly endoscopic, and transsphenoidal approach to access the sellar region.…”

“…Complete cyst excision is less favored than decompression due to increased risk of postoperative complications, particularly endocrinopathies, and intra-operative CSF leak as well as possible injury to the carotid artery or the optic apparatus. [ 2 , 5 , 7 , 12 ]…”

“…One technique that has been popularized is the cyst marsupialization, where the cyst wall is widely opened and the cavity is opened to drain direct into the sphenoid sinus. [ 12 ] Marsupialization, also avoids inadvertent injury to surrounding structures when compared to the total resection. By working only on the anterior surface of the cyst, the risk of intraoperative CSF leak is also decreased.…”

“…By working only on the anterior surface of the cyst, the risk of intraoperative CSF leak is also decreased. [ 12 ] In several cases, instead of leaving the marsupialized cyst simply open, a free mucosal graft harvested from the nasal septum, nasal floor, or resected middle turbinate, is placed along the anteroinferior edge of the cyst tract. This provides reinforcement of the draining site and reduces mucosal crusting after surgery.…”

“…Stenting to open the cavity following marsupialization allows effective treatment, with favorable long-term outcomes. [ 12 ] Some external devices such as steroid-eluting stents and silicone stenting, have already been used. However, insertion of a foreign object, may cause trauma to the cyst wall, increase bacterial infections, and foreign body reactions.…”