Transnasal Endoscopic Approach for the Revision of Rathke's Cyst and Successful Long-Term Follow-Up: A Case Report

Rathke's cleft cysts are benign epithelial-lined sellar and suprasellar lesions that are often incidental findings but can cause visual deficits, hypopituitarism, and headaches when they enlarge and compress adjacent structures. Recurrence after surgical treatment remains challenging despite various surgical approaches. Marsupialization has emerged as an alternative technique for complex recurrent cases, establishing permanent communication between the cyst and the nasal cavity while minimizing surgical risk. We present a case of a 76-year-old man with type 2 diabetes mellitus, a history of meningeal tuberculosis, and panhypopituitarism who experienced progressive visual decline following multiple failed Rathke's cleft cyst surgeries. Ophthalmological evaluation revealed right temporal hemianopsia and reduced visual acuity, and magnetic resonance imaging confirmed a recurrent sellar-suprasellar lesion compressing the optic chiasm. Revision endoscopic endonasal surgery was performed using the marsupialization technique, including a type III sphenoidotomy, cyst aperture, dural membrane eversion toward the nasal cavity, and nasoseptal flap placement on the cyst floor. Surgery was completed without complications. At eight-month follow-up, the patient demonstrated complete resolution of hemianopsia, improved visual acuity, and stable postoperative changes without cyst reaccumulation on imaging. Endoscopic transnasal marsupialization represents a safe and effective therapeutic option for recurrent Rathke's cleft cysts, particularly following multiple failed interventions, providing permanent drainage while minimizing manipulation of delicate neurovascular structures. It may also potentially reduce recurrence rates and improve functional outcomes in complex cases.