What is the appropriate workup and referral for a patient diagnosed with empty sella (sella turcica) and normal parathyroid (Parathyroid Hormone, PTH) laboratory results?

Workup and Referral for Empty Sella with Normal Parathyroid Labs

For a patient with empty sella and normal parathyroid laboratory results, the appropriate workup should include comprehensive hormonal screening and MRI imaging, with referral to endocrinology if any pituitary dysfunction is detected. 1, 2

Initial Evaluation

• Empty sella is characterized by flattening of the pituitary gland with cerebrospinal fluid filling the sella turcica, and is often an incidental finding on imaging studies 2, 3
• Approximately 30% of patients with empty sella may demonstrate some degree of hypopituitarism upon testing, although most remain asymptomatic 2, 3
• MRI using high-resolution pituitary protocols is the preferred diagnostic imaging modality for evaluation of empty sella and can confirm the diagnosis even without IV contrast 1

Recommended Hormonal Workup

• Basic hormonal screening should include: 2, 4

  • Thyroid function tests (TSH, free T4) to rule out central hypothyroidism
  • Morning cortisol and ACTH to assess adrenal axis
  • Sex hormones (testosterone in men, estradiol in women, FSH, LH)
  • Prolactin levels

• The most common hormone abnormalities associated with empty sella include: 5, 3

  • Thyroid-stimulating hormone, T3, and T4 deficiencies (seen in up to 48% of cases)
  • Elevated prolactin levels (seen in approximately 28% of cases)

Imaging Considerations

• MRI with high-resolution pituitary protocols is the gold standard for characterizing empty sella 1, 3
• If MRI has already confirmed empty sella, no additional urgent imaging is typically needed 2
• Key MRI features to evaluate include: 1, 5
  • Pituitary gland height (reduced height correlates with higher risk of hormonal deficiencies)
  • Distance between pituitary stalk and optic nerve
  • Presence of any other sellar or parasellar lesions

Referral Recommendations

• Endocrinology referral is indicated if: 2, 4

  • Any hormonal abnormalities are detected on screening
  • Patient has symptoms suggestive of pituitary dysfunction (fatigue, cold intolerance, sexual dysfunction)
  • Follow-up is needed for monitoring of hormonal status

• Ophthalmology referral should be considered if: 4

  • Visual symptoms are present
  • There are concerns about increased intracranial pressure
  • Optic chiasm compression is noted on imaging

Follow-up Recommendations

• If all hormonal screening is normal and the patient is asymptomatic: 2, 3

  • Careful reevaluation at 24-36 months is suggested due to the low risk of progression
  • No immediate intervention is typically required

• If hormonal deficiencies are detected: 1, 6

  • Hormone replacement therapy should be initiated under endocrinology guidance
  • Regular monitoring of hormone levels is necessary

Common Pitfalls to Avoid

• Attributing unrelated symptoms directly to empty sella without considering more common causes 2, 4
• Missing rare but important hormonal deficiencies by not performing appropriate screening 2
• Failing to recognize when empty sella might be part of a more significant condition, such as pseudotumor cerebri 4
• Overlooking the possibility of primary hypothyroidism, which can rarely coexist with empty sella syndrome 7