The Journal of Craniofacial Surgery
Volume 27, Number 8, November 2016
In the paranasal region the implant promotes the restoration of facial contour in lateral and inferior areas to the nasal cavity. The implant should be trimmed and adapted to allow selective increase according to the aesthetic needs of the patient.18 In patients with midface hypoplasia, the use of these implants results in significant changes in nasolabial angle and in columella inclination.19 Porous polyethylene implants should be covered with a thick layer of connective tissue to minimize tissue erosion and facilitate its incorporation. Encapsulation and implant movement are responsible for most complications.20 In this clinical report no complications were observed. The association of these implants with orthognathic surgery was effective to restore soft tissue morphology in paranasal region and to improve the facial aesthetics.
Brief Clinical Studies
Spontaneous Involution of a Rathke Cleft Cyst Lei Cheng, MD, Pin Guo, MD, Peng Jin, MD, Huanting Li, MD, Mingchao Fan, MD, and Enyuan Cai, MD Abstract: Rathke cleft cysts (RCCs) are nonneoplastic lesions that are thought to be the remnants of Rathke cleft pouch. The authors report a patient presented with a headache and was diagnosed with RCC on imaging. The lesion underwent spontaneous involution. The authors suggest that patients presenting solely with a headache to be treated conservatively, because it is uncertain whether a headache is definitively associated with RCCs and because there is the possibility of spontaneous regression.
REFERENCES 1. Terino EO. Alloplastic facial contouring: surgery of the fourth plane. Aesthetic Plast Surg 1992;16:195–212 2. Arnett GW, Bergmann RT. Facial keys to orthodontic diagnosis and treatment. Part II. Am J Orthod Dentofac Orthop 1993;103:299–312 3. Fattahi T. Aesthetic surgery to augment orthognathic surgery. Oral Maxillofac Surg Clin North Am 2007;19:435–447 4. Robiony M, Costa F, Demitri V, et al. Simultaneous malaroplasty with porous polyethylene implants and orthognathic surgery for correction of malar deficiency. J Oral Maxillofac Surg 1998;56:734–741 5. Ronchi P, Chiapasco M, Frattini D. Modified intraoral maxillomalar osteotomy: long term result in I6 consecutive cases. J Craniomaxillofac Surg 1997;25:46–50 6. Wilkinson TS. Complications in aesthetic malar augmentation. Plast Reconstr Surg 1983;71:643–649 7. Block MS, Zide MF, Kent JN. Proplast augmentation for posttraumatic zygomatic deficiency. Oral Surg Oral Med Oral Pathol 1984;57:123–131 8. Salyer KE, Hall CD. Porous hydroxyapatite as an onlay bonegraft substitute for maxillofacial surgery. Plast Reconstr Surg 1989;84:236–244 9. Jones RHB, Ching M. Intraoral zygomatic osteotomy for correction of malar deficiency. J Oral Maxillofac Surg 1995;53:483–485 10. Van Sickels JE, Tiner BD. A combined Le Fort I and bilateral zygomatic osteotomy for management of midface and maxillary deficiency. J Oral Maxillofac Surg 1994;52:327–331 11. Couldwell WT, Chen TC, Weiss MH, et al. Cranioplasty with the Medpor porous polyethylene flexblock implant. Technical note. J Neurosurg 1994;81:483–486 12. Gabrielli MFR, Ambrizzi DR, Okamoto T, et al. Calvarial reconstruction through bone grafts and high density porous polyethylene implants. Comparative study in rabbits. Salusvita 2000;19:31–45 13. Soparkar CN, Wong JF, Patrinely JR, et al. Porous polyethylene implant fibrovascularization rate is affected by tissue wrapping, agarose coating, and insertion site. Ophthal Plast Reconstr Surg 2000;16:330–336 14. Rubin PA, Bilyk JR, Shore JW. Orbital reconstruction using porous polyethylene sheets. Ophthalmology 1994;101:1697–1708 15. Wellisz T. Clinical experience with the Medpor porous polyethylene implant. Aesthetic Plast Surg 1993;17:339–344 16. Weinzweig J, Pantaloni M, Spangenberger A, et al. Osteochondral reconstruction of a non-weight-bearing joint using a high-density porous polyethylene implant. Plast Reconstr Surg 2000;106: 1547–1554 17. Sclafani AP, Thomas JR, Cox AJ, et al. Clinical and histologic response of subcutaneous expanded polytetrafluoroethylene (Gore-Tex) and porous high-density polyethylene (Medpor) implants to acute and early infection. Arch Otolaryngol Head Neck Surg 1997;123:328–336 18. Yaremchuk MJ1, Israeli D. Paranasal implants for correction of midface concavity. Plast Reconstr Surg 1998;102:1676–1684 19. Kwon TG, Kang SM, Hwang HD. Three-dimensional soft tissue change after paranasal augmentation with porous polyethylene. Int J Oral Maxillofac Surg 2014;43:816–823 20. Yaremchuk MJ. Facial skeletal reconstruction using porous polyethylene implants. Plast Reconstr Surg 2003;111:1818–1827 #
Key Words: Rathke cleft cysts, spontaneous regression
R
athke cleft cysts (RCCs) are nonneoplastic lesions that are thought to be the remnants of Rathke cleft pouch, which formats the adenohypophysis and pars intermedia. Rathke cleft cysts are usually asymptomatic. When symptoms are present, they may include a headache, visual loss, and/or endocrinopathies. Symptomatic patients are usually treated surgically. However, it is unclear about the prognosis of symptomatic patients who did not undergo surgery. We report a patient presented with a headache and was diagnosed with RCC on imaging. The lesion underwent spontaneous involution. This phenomenon has rarely been reported in the literature1–8 (Table 1).
CLINICAL REPORT This 50-year-old woman presents with a 1-year history of a headache. Magnetic resonance imaging (MRI) demonstrated a cystic sellar lesion extending into the suprasellar space (Fig. 1). The cyst was isointense on T1-weighted imaging and hyperintense on T2weighted imaging without rim enhancement (Figs. 1 and 2). There was a mass (hyperintense on T1-weighted imaging and hypointense on T2-weighted imaging), which was called ‘‘waxy nodule’’ in the cyst (Fig. 1). Neurological examination and Pituitary hormone studies were normal. Transsphenoidal resection was discussed with the patient and her family. The operation was postponed for the personal reason of patient. Ten months later, the patient came to our hospital and asked for surgery. Repeated MR imaging showed the spontaneous decrease in cyst volume (Fig. 2). Surgery was canceled and a close observation was recommended. Twenty-six months later, the MR imaging showed no recurrence of the Rathke cleft cyst (Fig. 2).
DISCUSSION General Description Rathke cleft cysts are the common intracranial lesion, which is thought to be the remnants of Rathke cleft pouch. Most of the RCCs From the Department of Neurosurgery, Affiliated Hospital of Qingdao University, Qingdao, China. Received June 8, 2016. Accepted for publication July 29, 2016. Address correspondence and reprint requests to Enyuan Cai, MD, Department of Neurosurgery, Affiliated Hospital of Qingdao University, Qingdao, Shandong, China; E-mail: [email protected] The authors report no conflicts of interest. Copyright # 2016 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000003132
e791 Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. 2016 Mutaz B. Habal, MD
The Journal of Craniofacial Surgery
Brief Clinical Studies
Volume 27, Number 8, November 2016
FIGURE 1. (A, B, MR images) Sagittal T1-weighted MR image (A) shows a cystic sellar lesion extending into the suprasellar space. Coronal T2-weighted MR image (B) shows a waxy nodule (white arrow) within the cyst. MR, magnetic resonance.
are rarely symptomatic. Symptoms, when they do occur, may include a headache, visual disturbances, and/or endocrinopathies attributable to hypopituitarism. Visual disturbances and endocrinological dysfunction are usually thought to be clear indication for surgery; whether headaches can be definitively linked to RCCs is not clear.1 It is also unclear about the prognosis of symptomatic patients who did not undergo surgery.
Radiological Evaluation Magnetic resonance imaging features of RCCs have been reported in many studies. It is suggested that the MRI intensity of cyst fluid is affected by protein, cholesterol, and mucopolysaccharide concentrations. In most patients, distinct rim enhancement
FIGURE 2. (A–F, sagittal and coronal contrast MR images) Sagittal (A) and coronal (D) show a cystic sellar lesion extending into the suprasellar space. Ring enhancement is absent. Sagittal (B) and coronal (E) images acquired 10 months later. Sagittal (C) and coronal (F) images acquired 26 months later.
was negative. Nishioka et al6 suggested that the presence of ‘‘waxy nodules’’ could be taken as the most reliable diagnostic indicator of RCCs. Our patient exhibited a lesion that was T1-isointense and T2hyperintense, suggesting not only moderate protein and mucopolysaccharide content but also significant water content. In addition, the lesion contained a nonenhancing intracystic nodule that was T1hyperintense and T2-hypointense relative to the remaining intracystic contents (Fig. 1). The intracystic nodules with these imaging
TABLE 1. Reported Patients of Spontaneous Regression of Rathke Cleft Cysts# Authors
Age
Sex
Suprasellar Extension
Igarashi2
25 46 34 58 59 30 15 14
F M M F F M F M
Yes Yes Yes Yes Yes Yes No Yes
Visual field defect Visual field defect Visual field defect Visual field defect Visual field defect Visual field defect Amenorrhea Headache
31
F
No
Headache, nausea, vertigo
N N 81 57 29 17 6 29 32 18 14 5
N N M M F F M F F F M M
No Yes Yes Yes No No Yes Yes No No No No
32
F
Yes
Saeki7 Simmons8 Nishio5
Nishioka6 Maruyama3 Hassan1
Cheng
Symptoms
MRI Characteristics
Time to Regression (mo)
Pituitary Function at Cyst Discovery
NA NA NA NA 1 0.5 3 3
NA NA NA NA Normal Low LH, FSH, GH Low LH, FSH, Estradiol Normal
NA Visual field defect headache Headache None, incidentally found Headache Headache, Aggressive behavior Headache Headache and spots in vision Headache w/ episodic blurry vision Headache, low percentile growth Low-percentile growth
T1: iso, T2: high thin wall enhancement T1: iso, T2: high thin wall enhancement T1: iso, T2: high thin wall enhancement T1: iso, T2: high thin wall enhancement T1: iso, T2: high thin wall enhancement T1: iso, T2: high thin wall enhancement T1: hypo, no wall enhancement T1: hyper, T2: hyper, w/ iso small nodule, thick wall enhancement T1: mixed intensity, T2: hypo thin wall enhancement T1: hyper T1: iso T1: iso, no wall enhancement T1: hypo, T2: hyper T1: hypo, T2: hypo T1: hypo, T2: hypo T1: hypo, T2: hypo T1: hypo, T2: hyper T1: hypo, T2: hyper T1: hypo, T2: hypo T1: hypo, T2: hypo T1: hypo, T2: hyper
NA NA 0.5 5 31 21 41 18 44 7 11 100
Headache
T1: hyper, T2-hypo
10
6
Normal Hypopituitarism NA Panhypopituitarism Low testosterone Normal Normal Normal Normal Normal Elevated ACTH GH slightly low Low testosterone and TSH (GH normal) Normal
The author of this article.
# 2016 Mutaz B. Habal, MD e792 Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 27, Number 8, November 2016
patterns, which is a waxy nodule, have been described as a characteristic of RCCs. However, because a surgical procedure and biopsy were not performed in this patient, we cannot definitively exclude the presence of another lesion such as craniopharyngioma or arachnoid cyst.
Regression Mechanism The spontaneous involution of RCCs is rare and the mechanism of it is unknown. There are several hypotheses: 1. Bleeding and reabsorb. Bleeding and blood absorption can cause the cyst size increased and decreased. According to the reports of Saeki et al7, the cyst regression may be explained by this mechanism. 8 2. Rupture. Simmons and Simmons reported an amenorrheic patient with a pituitary cyst. The patient was recommended surgical removal of the cyst. Magnetic resonance imaging determined several days prior to surgery showed that the lesion decreased. Amhaz et al1 reported a 32-year-old woman, MRI revealed a decrease in the size of RCC after vaginal delivery. They hypothesized that regression of the cyst was due to rupture. 3 3. Steroid therapy. Maruyama et al reported a patient of RCC, the size of the cyst was associated with the dose of cortisol replacement. They thought that the antiinflammatory effect of glucocorticoid might be the main factor. Before the repeated MRI (in preparation for surgery), the patient we reported was treated by prednisone acetate tablets (prednisone, Xianju pharma) for 2 days (5 mg/day). However, we are not sure whether the cyst had disappeared before taking medicine.
CONCLUSION The natural history of RCC requires further study. Surgery is recommended for the patients presenting with visual or endocrine dysfunction to resolve the mass effect of RCCs. We suggest that patients presenting solely with a headache to be treated conservatively, because it is uncertain whether a headache is definitively associated with RCCs and because there is the possibility of spontaneous regression. The role of medical therapy in promoting spontaneous involution of RCCs remains unclear.
Brief Clinical Studies
Evaluation of Eyeball and Orbit in Relation to Gender and Age Cenk Murat O¨zer, MD, Ibrahim Ilker O¨z, MD,y Ismail S¸erifog˘lu, MD,z Mustafa C ¸ ag˘atay Bu¨yu¨kuysal, PhD,§ jj and C ¸ ag˘atay Barut, MD, PhD Abstract: The orbital aperture is the entrance to the orbit in which most important visual structures such as the eyeball and the optic nerve are found. It is vital not only for the visual system but also for the evaluation and recognition of the face. Eyeball volume is essential for diagnosing microphthalmos or buphthalmos in several eye disorders. Knowing the length of the optic nerve is necessary in selecting the right instruments for enucleation. Therefore, the aim of this study was to evaluate eyeball volume, orbital aperture, and optic nerve dimensions for a morphological description in a Turkish population sample according to gender and body side. Paranasal sinus computed tomography (CT) scans of 198 individuals (83 females, 115 males) aged between 5 and 74 years were evaluated retrospectively. The dimensions of orbital aperture, axial length and volume of eyeball, and diameter and length of the intraorbital part of the optic nerve were measured. Computed tomography examinations were performed on an Activion 16 CT Scanner (Toshiba Medical Systems, 2008 Japan). The CT measurements were calculated by using OsiriX software on a personal computer. All parameters were evaluated according to gender and right/left sides. A statistically significant difference between genders was found with respect to axial length of eyeball, optic nerve diameter, dimensions of orbital aperture on both sides, and right optic nerve length. Furthermore, certain statistically significant side differences were also found. There were statistically significant correlations between age and the axial length of the eyeball, optic nerve diameter, and the transverse length of the orbital aperture on both sides for the whole study group. In this study we determined certain morphometric parameters of the orbit. These outcomes may be helpful in developing a database to determine normal orbit values for the Turkish population so that quantitative assessment of orbital disease and orbital deformities will be evaluated both for preoperative planning and for assessing postoperative outcomes.
REFERENCES 1. Amhaz HH, Chamoun RB, Waguespack SG, et al. Spontaneous involution of Rathke cleft cysts: is it rare or just underreported? J Neurosurg 2010;112:1327–1332 2. Igarashi T, Saeki N, Yamaura A. Long-term magnetic resonance imaging follow-up of asymptomatic sellar tumors—their natural history and surgical indications. Neurol Med Chir (Tokyo) 1999;39:592–598 3. Maruyama H, Iwasaki Y, Tsugita M, et al. Rathke’s cleft cyst with shortterm size changes in response to glucocorticoid replacement. Endocr J 2008;55:425–428 4. Munich SA, Leonardo J. Spontaneous involution of a Rathke’s cleft cyst in a patient with normal cortisol secretion. Surg Neurol Int 2012;3:42 5. Nishio S, Morioka T, Suzuki S, et al. Spontaneous regression of a pituitary cyst: report of two cases. Clin Imaging 2001;25:15–17 6. Nishioka H, Haraoka J, Izawa H, et al. Magnetic resonance imaging, clinical manifestations, and management of Rathke’s cleft cyst. Clin Endocrinol (Oxf) 2006;64:184–188 7. Saeki N, Kubota M, Yamaura A, et al. Fluctuating visual field defects in Rathke’s cleft cysts: MRI analysis. J Clin Neurosci 1999;6:524–527 8. Simmons JD, Simmons LA. Spontaneous regression of a pituitary cyst. Neuroradiology 1999;41:27–29 #
Key Words: Eyeball volume, optic nerve diameter, optic nerve length, orbital aperture From the Department of Anatomy; yDepartment of Radiology, Faculty of Medicine, Bu¨lent Ecevit University, Zonguldak; zDepartment of Radiology, Bagcilar Training and Research Hospital, Istanbul; §Department of Biostatistics, Faculty of Medicine, Bu¨lent Ecevit University, Zonguldak; and jjDepartment of Anatomy, Faculty of Medicine, Bahc¸es¸ehir University, Istanbul, Turkey. Received April 4, 2016. Accepted for publication July 28, 2016. Address correspondence and reprint requests to C ¸ ag˘atay Barut, MD, PhD, Department of Anatomy, Faculty of Medicine, Bahc¸es¸ehir University, Sahrayicedit Mah, Batman Sokak No: 66-68, Go¨ztepe, Istanbul 34600, Turkey; E-mail: [email protected] The authors report no conflicts of interest. Copyright # 2016 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000003133
e793 Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. 2016 Mutaz B. Habal, MD
Volume 27, Number 8, November 2016
In the paranasal region the implant promotes the restoration of facial contour in lateral and inferior areas to the nasal cavity. The implant should be trimmed and adapted to allow selective increase according to the aesthetic needs of the patient.18 In patients with midface hypoplasia, the use of these implants results in significant changes in nasolabial angle and in columella inclination.19 Porous polyethylene implants should be covered with a thick layer of connective tissue to minimize tissue erosion and facilitate its incorporation. Encapsulation and implant movement are responsible for most complications.20 In this clinical report no complications were observed. The association of these implants with orthognathic surgery was effective to restore soft tissue morphology in paranasal region and to improve the facial aesthetics.
Brief Clinical Studies
Spontaneous Involution of a Rathke Cleft Cyst Lei Cheng, MD, Pin Guo, MD, Peng Jin, MD, Huanting Li, MD, Mingchao Fan, MD, and Enyuan Cai, MD Abstract: Rathke cleft cysts (RCCs) are nonneoplastic lesions that are thought to be the remnants of Rathke cleft pouch. The authors report a patient presented with a headache and was diagnosed with RCC on imaging. The lesion underwent spontaneous involution. The authors suggest that patients presenting solely with a headache to be treated conservatively, because it is uncertain whether a headache is definitively associated with RCCs and because there is the possibility of spontaneous regression.
REFERENCES 1. Terino EO. Alloplastic facial contouring: surgery of the fourth plane. Aesthetic Plast Surg 1992;16:195–212 2. Arnett GW, Bergmann RT. Facial keys to orthodontic diagnosis and treatment. Part II. Am J Orthod Dentofac Orthop 1993;103:299–312 3. Fattahi T. Aesthetic surgery to augment orthognathic surgery. Oral Maxillofac Surg Clin North Am 2007;19:435–447 4. Robiony M, Costa F, Demitri V, et al. Simultaneous malaroplasty with porous polyethylene implants and orthognathic surgery for correction of malar deficiency. J Oral Maxillofac Surg 1998;56:734–741 5. Ronchi P, Chiapasco M, Frattini D. Modified intraoral maxillomalar osteotomy: long term result in I6 consecutive cases. J Craniomaxillofac Surg 1997;25:46–50 6. Wilkinson TS. Complications in aesthetic malar augmentation. Plast Reconstr Surg 1983;71:643–649 7. Block MS, Zide MF, Kent JN. Proplast augmentation for posttraumatic zygomatic deficiency. Oral Surg Oral Med Oral Pathol 1984;57:123–131 8. Salyer KE, Hall CD. Porous hydroxyapatite as an onlay bonegraft substitute for maxillofacial surgery. Plast Reconstr Surg 1989;84:236–244 9. Jones RHB, Ching M. Intraoral zygomatic osteotomy for correction of malar deficiency. J Oral Maxillofac Surg 1995;53:483–485 10. Van Sickels JE, Tiner BD. A combined Le Fort I and bilateral zygomatic osteotomy for management of midface and maxillary deficiency. J Oral Maxillofac Surg 1994;52:327–331 11. Couldwell WT, Chen TC, Weiss MH, et al. Cranioplasty with the Medpor porous polyethylene flexblock implant. Technical note. J Neurosurg 1994;81:483–486 12. Gabrielli MFR, Ambrizzi DR, Okamoto T, et al. Calvarial reconstruction through bone grafts and high density porous polyethylene implants. Comparative study in rabbits. Salusvita 2000;19:31–45 13. Soparkar CN, Wong JF, Patrinely JR, et al. Porous polyethylene implant fibrovascularization rate is affected by tissue wrapping, agarose coating, and insertion site. Ophthal Plast Reconstr Surg 2000;16:330–336 14. Rubin PA, Bilyk JR, Shore JW. Orbital reconstruction using porous polyethylene sheets. Ophthalmology 1994;101:1697–1708 15. Wellisz T. Clinical experience with the Medpor porous polyethylene implant. Aesthetic Plast Surg 1993;17:339–344 16. Weinzweig J, Pantaloni M, Spangenberger A, et al. Osteochondral reconstruction of a non-weight-bearing joint using a high-density porous polyethylene implant. Plast Reconstr Surg 2000;106: 1547–1554 17. Sclafani AP, Thomas JR, Cox AJ, et al. Clinical and histologic response of subcutaneous expanded polytetrafluoroethylene (Gore-Tex) and porous high-density polyethylene (Medpor) implants to acute and early infection. Arch Otolaryngol Head Neck Surg 1997;123:328–336 18. Yaremchuk MJ1, Israeli D. Paranasal implants for correction of midface concavity. Plast Reconstr Surg 1998;102:1676–1684 19. Kwon TG, Kang SM, Hwang HD. Three-dimensional soft tissue change after paranasal augmentation with porous polyethylene. Int J Oral Maxillofac Surg 2014;43:816–823 20. Yaremchuk MJ. Facial skeletal reconstruction using porous polyethylene implants. Plast Reconstr Surg 2003;111:1818–1827 #
Key Words: Rathke cleft cysts, spontaneous regression
R
athke cleft cysts (RCCs) are nonneoplastic lesions that are thought to be the remnants of Rathke cleft pouch, which formats the adenohypophysis and pars intermedia. Rathke cleft cysts are usually asymptomatic. When symptoms are present, they may include a headache, visual loss, and/or endocrinopathies. Symptomatic patients are usually treated surgically. However, it is unclear about the prognosis of symptomatic patients who did not undergo surgery. We report a patient presented with a headache and was diagnosed with RCC on imaging. The lesion underwent spontaneous involution. This phenomenon has rarely been reported in the literature1–8 (Table 1).
CLINICAL REPORT This 50-year-old woman presents with a 1-year history of a headache. Magnetic resonance imaging (MRI) demonstrated a cystic sellar lesion extending into the suprasellar space (Fig. 1). The cyst was isointense on T1-weighted imaging and hyperintense on T2weighted imaging without rim enhancement (Figs. 1 and 2). There was a mass (hyperintense on T1-weighted imaging and hypointense on T2-weighted imaging), which was called ‘‘waxy nodule’’ in the cyst (Fig. 1). Neurological examination and Pituitary hormone studies were normal. Transsphenoidal resection was discussed with the patient and her family. The operation was postponed for the personal reason of patient. Ten months later, the patient came to our hospital and asked for surgery. Repeated MR imaging showed the spontaneous decrease in cyst volume (Fig. 2). Surgery was canceled and a close observation was recommended. Twenty-six months later, the MR imaging showed no recurrence of the Rathke cleft cyst (Fig. 2).
DISCUSSION General Description Rathke cleft cysts are the common intracranial lesion, which is thought to be the remnants of Rathke cleft pouch. Most of the RCCs From the Department of Neurosurgery, Affiliated Hospital of Qingdao University, Qingdao, China. Received June 8, 2016. Accepted for publication July 29, 2016. Address correspondence and reprint requests to Enyuan Cai, MD, Department of Neurosurgery, Affiliated Hospital of Qingdao University, Qingdao, Shandong, China; E-mail: [email protected] The authors report no conflicts of interest. Copyright # 2016 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000003132
e791 Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. 2016 Mutaz B. Habal, MD
The Journal of Craniofacial Surgery
Brief Clinical Studies
Volume 27, Number 8, November 2016
FIGURE 1. (A, B, MR images) Sagittal T1-weighted MR image (A) shows a cystic sellar lesion extending into the suprasellar space. Coronal T2-weighted MR image (B) shows a waxy nodule (white arrow) within the cyst. MR, magnetic resonance.
are rarely symptomatic. Symptoms, when they do occur, may include a headache, visual disturbances, and/or endocrinopathies attributable to hypopituitarism. Visual disturbances and endocrinological dysfunction are usually thought to be clear indication for surgery; whether headaches can be definitively linked to RCCs is not clear.1 It is also unclear about the prognosis of symptomatic patients who did not undergo surgery.
Radiological Evaluation Magnetic resonance imaging features of RCCs have been reported in many studies. It is suggested that the MRI intensity of cyst fluid is affected by protein, cholesterol, and mucopolysaccharide concentrations. In most patients, distinct rim enhancement
FIGURE 2. (A–F, sagittal and coronal contrast MR images) Sagittal (A) and coronal (D) show a cystic sellar lesion extending into the suprasellar space. Ring enhancement is absent. Sagittal (B) and coronal (E) images acquired 10 months later. Sagittal (C) and coronal (F) images acquired 26 months later.
was negative. Nishioka et al6 suggested that the presence of ‘‘waxy nodules’’ could be taken as the most reliable diagnostic indicator of RCCs. Our patient exhibited a lesion that was T1-isointense and T2hyperintense, suggesting not only moderate protein and mucopolysaccharide content but also significant water content. In addition, the lesion contained a nonenhancing intracystic nodule that was T1hyperintense and T2-hypointense relative to the remaining intracystic contents (Fig. 1). The intracystic nodules with these imaging
TABLE 1. Reported Patients of Spontaneous Regression of Rathke Cleft Cysts# Authors
Age
Sex
Suprasellar Extension
Igarashi2
25 46 34 58 59 30 15 14
F M M F F M F M
Yes Yes Yes Yes Yes Yes No Yes
Visual field defect Visual field defect Visual field defect Visual field defect Visual field defect Visual field defect Amenorrhea Headache
31
F
No
Headache, nausea, vertigo
N N 81 57 29 17 6 29 32 18 14 5
N N M M F F M F F F M M
No Yes Yes Yes No No Yes Yes No No No No
32
F
Yes
Saeki7 Simmons8 Nishio5
Nishioka6 Maruyama3 Hassan1
Cheng
Symptoms
MRI Characteristics
Time to Regression (mo)
Pituitary Function at Cyst Discovery
NA NA NA NA 1 0.5 3 3
NA NA NA NA Normal Low LH, FSH, GH Low LH, FSH, Estradiol Normal
NA Visual field defect headache Headache None, incidentally found Headache Headache, Aggressive behavior Headache Headache and spots in vision Headache w/ episodic blurry vision Headache, low percentile growth Low-percentile growth
T1: iso, T2: high thin wall enhancement T1: iso, T2: high thin wall enhancement T1: iso, T2: high thin wall enhancement T1: iso, T2: high thin wall enhancement T1: iso, T2: high thin wall enhancement T1: iso, T2: high thin wall enhancement T1: hypo, no wall enhancement T1: hyper, T2: hyper, w/ iso small nodule, thick wall enhancement T1: mixed intensity, T2: hypo thin wall enhancement T1: hyper T1: iso T1: iso, no wall enhancement T1: hypo, T2: hyper T1: hypo, T2: hypo T1: hypo, T2: hypo T1: hypo, T2: hypo T1: hypo, T2: hyper T1: hypo, T2: hyper T1: hypo, T2: hypo T1: hypo, T2: hypo T1: hypo, T2: hyper
NA NA 0.5 5 31 21 41 18 44 7 11 100
Headache
T1: hyper, T2-hypo
10
6
Normal Hypopituitarism NA Panhypopituitarism Low testosterone Normal Normal Normal Normal Normal Elevated ACTH GH slightly low Low testosterone and TSH (GH normal) Normal
The author of this article.
# 2016 Mutaz B. Habal, MD e792 Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 27, Number 8, November 2016
patterns, which is a waxy nodule, have been described as a characteristic of RCCs. However, because a surgical procedure and biopsy were not performed in this patient, we cannot definitively exclude the presence of another lesion such as craniopharyngioma or arachnoid cyst.
Regression Mechanism The spontaneous involution of RCCs is rare and the mechanism of it is unknown. There are several hypotheses: 1. Bleeding and reabsorb. Bleeding and blood absorption can cause the cyst size increased and decreased. According to the reports of Saeki et al7, the cyst regression may be explained by this mechanism. 8 2. Rupture. Simmons and Simmons reported an amenorrheic patient with a pituitary cyst. The patient was recommended surgical removal of the cyst. Magnetic resonance imaging determined several days prior to surgery showed that the lesion decreased. Amhaz et al1 reported a 32-year-old woman, MRI revealed a decrease in the size of RCC after vaginal delivery. They hypothesized that regression of the cyst was due to rupture. 3 3. Steroid therapy. Maruyama et al reported a patient of RCC, the size of the cyst was associated with the dose of cortisol replacement. They thought that the antiinflammatory effect of glucocorticoid might be the main factor. Before the repeated MRI (in preparation for surgery), the patient we reported was treated by prednisone acetate tablets (prednisone, Xianju pharma) for 2 days (5 mg/day). However, we are not sure whether the cyst had disappeared before taking medicine.
CONCLUSION The natural history of RCC requires further study. Surgery is recommended for the patients presenting with visual or endocrine dysfunction to resolve the mass effect of RCCs. We suggest that patients presenting solely with a headache to be treated conservatively, because it is uncertain whether a headache is definitively associated with RCCs and because there is the possibility of spontaneous regression. The role of medical therapy in promoting spontaneous involution of RCCs remains unclear.
Brief Clinical Studies
Evaluation of Eyeball and Orbit in Relation to Gender and Age Cenk Murat O¨zer, MD, Ibrahim Ilker O¨z, MD,y Ismail S¸erifog˘lu, MD,z Mustafa C ¸ ag˘atay Bu¨yu¨kuysal, PhD,§ jj and C ¸ ag˘atay Barut, MD, PhD Abstract: The orbital aperture is the entrance to the orbit in which most important visual structures such as the eyeball and the optic nerve are found. It is vital not only for the visual system but also for the evaluation and recognition of the face. Eyeball volume is essential for diagnosing microphthalmos or buphthalmos in several eye disorders. Knowing the length of the optic nerve is necessary in selecting the right instruments for enucleation. Therefore, the aim of this study was to evaluate eyeball volume, orbital aperture, and optic nerve dimensions for a morphological description in a Turkish population sample according to gender and body side. Paranasal sinus computed tomography (CT) scans of 198 individuals (83 females, 115 males) aged between 5 and 74 years were evaluated retrospectively. The dimensions of orbital aperture, axial length and volume of eyeball, and diameter and length of the intraorbital part of the optic nerve were measured. Computed tomography examinations were performed on an Activion 16 CT Scanner (Toshiba Medical Systems, 2008 Japan). The CT measurements were calculated by using OsiriX software on a personal computer. All parameters were evaluated according to gender and right/left sides. A statistically significant difference between genders was found with respect to axial length of eyeball, optic nerve diameter, dimensions of orbital aperture on both sides, and right optic nerve length. Furthermore, certain statistically significant side differences were also found. There were statistically significant correlations between age and the axial length of the eyeball, optic nerve diameter, and the transverse length of the orbital aperture on both sides for the whole study group. In this study we determined certain morphometric parameters of the orbit. These outcomes may be helpful in developing a database to determine normal orbit values for the Turkish population so that quantitative assessment of orbital disease and orbital deformities will be evaluated both for preoperative planning and for assessing postoperative outcomes.
REFERENCES 1. Amhaz HH, Chamoun RB, Waguespack SG, et al. Spontaneous involution of Rathke cleft cysts: is it rare or just underreported? J Neurosurg 2010;112:1327–1332 2. Igarashi T, Saeki N, Yamaura A. Long-term magnetic resonance imaging follow-up of asymptomatic sellar tumors—their natural history and surgical indications. Neurol Med Chir (Tokyo) 1999;39:592–598 3. Maruyama H, Iwasaki Y, Tsugita M, et al. Rathke’s cleft cyst with shortterm size changes in response to glucocorticoid replacement. Endocr J 2008;55:425–428 4. Munich SA, Leonardo J. Spontaneous involution of a Rathke’s cleft cyst in a patient with normal cortisol secretion. Surg Neurol Int 2012;3:42 5. Nishio S, Morioka T, Suzuki S, et al. Spontaneous regression of a pituitary cyst: report of two cases. Clin Imaging 2001;25:15–17 6. Nishioka H, Haraoka J, Izawa H, et al. Magnetic resonance imaging, clinical manifestations, and management of Rathke’s cleft cyst. Clin Endocrinol (Oxf) 2006;64:184–188 7. Saeki N, Kubota M, Yamaura A, et al. Fluctuating visual field defects in Rathke’s cleft cysts: MRI analysis. J Clin Neurosci 1999;6:524–527 8. Simmons JD, Simmons LA. Spontaneous regression of a pituitary cyst. Neuroradiology 1999;41:27–29 #
Key Words: Eyeball volume, optic nerve diameter, optic nerve length, orbital aperture From the Department of Anatomy; yDepartment of Radiology, Faculty of Medicine, Bu¨lent Ecevit University, Zonguldak; zDepartment of Radiology, Bagcilar Training and Research Hospital, Istanbul; §Department of Biostatistics, Faculty of Medicine, Bu¨lent Ecevit University, Zonguldak; and jjDepartment of Anatomy, Faculty of Medicine, Bahc¸es¸ehir University, Istanbul, Turkey. Received April 4, 2016. Accepted for publication July 28, 2016. Address correspondence and reprint requests to C ¸ ag˘atay Barut, MD, PhD, Department of Anatomy, Faculty of Medicine, Bahc¸es¸ehir University, Sahrayicedit Mah, Batman Sokak No: 66-68, Go¨ztepe, Istanbul 34600, Turkey; E-mail: [email protected] The authors report no conflicts of interest. Copyright # 2016 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000003133
e793 Copyright © 2016 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. 2016 Mutaz B. Habal, MD
