Is it true that most patients with empty sella syndrome do not have associated pituitary hormone deficiencies and typically have a functioning pituitary gland?

Empty Sella Syndrome and Pituitary Function

The statement is partially true, but it's important to note that up to 40% of patients with empty sella syndrome may have at least one hormone deficiency, making comprehensive hormonal evaluation necessary in all cases. 1

Understanding Empty Sella Syndrome

Empty sella syndrome (ESS) is characterized by:

• The sella turcica appearing to be filled with cerebrospinal fluid (CSF)
• The pituitary gland being flattened against the floor of the sella turcica
• This flattening creates the radiological appearance of an "empty" sella

The pathophysiology typically involves:

• Herniation of the subarachnoid space into the sella turcica
• Compression of the pituitary gland against the sellar floor
• The pituitary gland remains present and can maintain function despite being flattened

Prevalence of Hormonal Deficiencies

Current evidence shows variable rates of pituitary dysfunction:

• According to the most recent guidelines, up to 40% of patients with empty sella syndrome may have at least one hormone deficiency 1
• A pooled analysis from 2018 found that the relative frequency of pituitary insufficiency in patients with primary empty sella syndrome was 52% (95% CI [38; 65]) 2
• This is significantly higher than the statement's claim that "most patients" have no deficiencies

Recommended Hormonal Evaluation

The proposed evaluation in the statement is appropriate but should be conducted with the understanding that hormonal deficiencies are common:

• Complete anterior pituitary axis assessment should include:
  • Thyroid function: TSH and free T4
  • Adrenal function: Morning cortisol (as mentioned, this is indeed a better marker than ACTH alone)
  • Gonadal function: LH, FSH, estradiol in premenopausal females, testosterone in males
  • Growth hormone axis: IGF-1
  • Prolactin levels

Clinical Implications and Follow-up

• If hormonal deficiencies are detected (which occurs in a substantial minority of patients), appropriate hormone replacement therapy should be initiated based on specific deficiencies 1
• Even with normal initial testing, periodic reassessment may be warranted as pituitary function can change over time
• The statement correctly notes that if there is concern for increased intracranial pressure or pseudotumor cerebri, referral to ophthalmology and/or neurology is appropriate

Common Pitfalls to Avoid

1. Assuming normal pituitary function: The evidence contradicts the assumption that "most" patients have normal function; a significant percentage have at least one deficiency
2. Inadequate testing: Failing to perform comprehensive hormonal evaluation could miss clinically significant deficiencies
3. Overlooking visual symptoms: Visual field testing should be considered to assess for potential compression of the optic chiasm 1
4. Missing associated conditions: Hypertension is a common finding in patients with empty sella syndrome and should be assessed 1

In summary, while the pituitary gland is indeed present and functioning in empty sella syndrome, comprehensive hormonal evaluation is necessary as a significant proportion of patients will have hormonal deficiencies requiring treatment.