Marsupialization of Rathke’s Cleft Cysts Does Not Increase the Risk of Postoperative Intracranial Infection

Objectives: Marsupialization of Rathke’s cleft cysts into the sphenoid sinus is a safe and effective technique which avoids the extracapsular dissection required for complete removal, with subsequent increased risk of endocrinopathies and CSF leak. However, the marsupialized cyst results in exposure of dura covered with only a single layer of epithelium directly into the nasal cavity. The objective of this study was to determine whether the risk of postoperative intracranial infection is increased in marsupialized Rathke’s cleft cysts, compared with patients undergoing skull base reconstruction after transnasal resection of pituitary adenomas.

Design: Retrospective chart review.

Setting: Two tertiary academic medical centers.

Participants: Patients undergoing endonasal endoscopic surgery for resection of pituitary lesions including Rathke’s cleft cysts (n = 72) and pituitary adenomas (n = 77) were identified between 2008 and 2019. Demographic data were collected including age (mean: 45 years), gender (35% male), BMI (mean: 28.7), type II diabetes mellitus (12.7%), active smoking (3.4%), presence of perioperative antibiotics (99.3%), method of skull base reconstruction, and prior skull base surgery (8.1%). Patients with Rathke’s cleft cysts who experienced intraoperative CSF leaks (19.4%) were excluded from the analysis.

Primary Outcome Measures: Development of postoperative intracranial infections including meningitis, abscess, or hypophysitis.

Results: The final study cohort included 58 patients undergoing endonasal endoscopic marsupialization of a Rathke’s cleft cyst in which the cyst wall was exposed to the sinonasal cavity at the completion of the case. There were 77 patients in the control group with pituitary adenomas who all underwent free mucosal graft reconstruction of the skull base defect. The mean follow-up period was 29 months for pituitary adenoma patients and 66 months for Rathke’s cleft cyst patients. There were no documented cases of intracranial infections, including meningitis, abscess, or hypophysitis. Nearly all patients (99.3%) received perioperative antibiotics including cefazolin (n = 142), clindamycin (n = 4), or vancomycin (n = 2). Within the pituitary adenoma cohort, 2.6% (2/77) of patients were readmitted for hyponatremia but were not found to have an intracranial infection.

Conclusion: Marsupialization of Rathke’s cleft cysts does not increase the risk of postoperative intracranial infections such as meningitis, brain abscess, or hypophysitis even though dura covered by a single layer of epithelium is exposed to the nasal cavity. Perioperative CSF penetrating antibiotic prophylaxis may not be indicated for routine transnasal marsupialization of Rathke’s cleft cysts given the low overall incidence of postoperative intracranial infection in this population.