Headache and the
Primary Empty Sella Syndrome
J. Dale Browne, MD, Robert I. Kohut, MD
\s=b\ Otolaryngologists frequently
counter patients with complaints of head-
aches. On occasion, normal physical
examination findings may be accompa-
nied by a roentgenographic enlargement
of the sella turcica. In the process of
evaluation for an intrasellar neoplasm, an
"empty sella" is occasionally discovered.
Patients with this condition commonly
have headaches, although a cause-effect
relationship is controversial. Endocrine
and visual disturbances, although rare,
necessitate periodic evaluation of these
patients.
(Arch Otolaryngol Head Neck Surg
1986;112:883-885)
Otolaryngologipatients
sts frequently
counter with com¬
en¬
plaints of "sinus headaches." The
presence of an enlarged sella on roent¬
genographic evaluation of the sinuses,
while suggestive of an intrasellar neo¬
plasm, is commonly identified on com¬
puted tomographic (CT) scan as
cerebrospinal fluid (CSF) density fill¬
ing the sella. The purpose of this
article is to bring to the attention of
Accepted for publication Oct 21, 1985.
From the Department of Surgery, Section on
Otolaryngology, Bowman Gray School of Medi-
cine, Wake Forest University, Winston-Salem,
NC.
Reprint requests to Department of Surgery,
Section on Otolaryngology, Bowman Gray School
of Medicine, Wake Forest University, 300 S Haw-
thorne Rd, Winston-Salem, NC 27103 (Dr
Kohut).
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en- the otolaryngologic community the
association of headache with "empty
sella" by reviewing its characteristics
and presenting an illustrative case
report.
The term empty sella was coined by
Busch1 in 1951 following 788 autopsies
of patients with no known pituitary
disease. Only 42% of the patients had
a complete sella diaphragm, while in
approximately 5%, the diaphragm
was a thin rim of tissue, 2 mm or less.
In these cases, the pituitary gland was
compressed to the bottom of the sella
with subarachnoid space filling the
majority of the intrasellar space.
Since then, primary and secondary
empty sella types have been identi¬
fied. A secondary empty sella is seen
following radiation or surgery on the
pituitary gland, reducing its size with
subsequent intrasellar herniation of
the suprasellar cistern. When there is
a no history of such intervention, a pri¬
mary empty sella exists, with those
patients having no coexisting pitu¬
itary tumor described as having the
primary empty sella syndrome
(ESS).2
REPORT OF A CASE
A 60-year-old man presented to the Oto¬
laryngology Clinic of Wake Forest Univer¬
sity Medical Center, Winston-Salem, NC,
with a chief complaint of continuous, mild,
nonpulsatile left-sided headaches for the
past three years. The pain originated from
the left retro-orbital area with radiation
into the frontal regions. His pain did not
prevent him from working, and he con¬
trolled the pain with acetaminophen. Two
years previously, he had been evaluated for
the same headaches by another otolaryn¬
gologist, who performed a septoplasty and
intranasal ethmoidectomies without relief
or alteration of the patient's symptoms.
Head and neck examination findings
were normal. No abnormalities were iden¬
tified on neurologic examination. Roent¬
genograms revealed well-aerated paranas-
al sinuses. On the lateral view, the sella
turcica was enlarged and deepened (Fig 1).
In evaluation of this finding, prolactin,
cortisol, growth hormone, follicle-stimu¬
lating hormone, luteinizing hormone, thy¬
roid-stimulating hormone, and thyroxine
levels were shown to be normal. Ophthal¬
mologic consultation found normal visual
fields and funduscopic examination re¬
sults. A CT head scanner (General Electric
8800) demonstrated intrasellar content
isodense with CSF in the ventricles, consis¬
tent with the diagnosis of ESS (Fig 2).
The patient was instructed to continue
the use of acetaminophen. He is to be
reevaluated on a yearly basis with re¬
peated pituitary function tests and oph¬
thalmologic examinations.
COMMENT
The anatomy of a primary empty
sella contains a deficient sella dia¬
phragm through which subarachnoid
space herniates into the sella, com-
 Fig 2.—Coronal reconstruction of sella turcica demonstrating sella
contents of equal density with cerebrospinal fluid in ventricles.

Fig 1.—Lateral view showing enlarged, deepened sella turcica (ar¬

rows).

Fig 3.—Normal relationship of meninges to human pituitary gland (left). In empty sella syndrome (right) arachnoid membrane herniates through
incompetent diaphragma sellae. CSF indicates cerebrospinal fluid (from Jordan et al8).

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 pressing the pituitary gland (Fig 3).
While a deficient sella diaphragm is
thought to be a prerequisite for devel¬
opment of an empty sella, there are a
variety of theories concerning the
mechanism behind the actual pro¬
lapse of arachnoid tissue. These
include rupture of a pituitary or intra¬
sellar arachnoid cyst, necrosis of a
pituitary adenoma, benign intracrani¬
al hypertension, and fluctuation of
CSF pressure with subsequent remod¬
eling of the sella turcica.3"5
The typical ESS patient is middle
aged, female, and has normal endo¬
crine function.2-610 When a pituitary
function abnormality is present, it is
most commonly hyperfunction sec¬
ondary to a microadenoma. Acromeg-
aly, amenorrhea-galactorrhea, and
Cushing's disease have been men¬
tioned in the literature.2-911 The
reported casesof demonstrated hypo-
function have involved corticotropin
deficiency, panhypopituitarism, and
impaired growth hormone response to
glucagon.2-910 There has been no corre¬
lation between the degree of empti¬
ness of the sella and pituitary func¬
tion.12
Visual symptoms and CSF rhinor¬
rhea are rare. In contrast, headaches
are the predominant complaint in
60% to 80% of patients found to have
ESS.6-9-1213 The characteristic headache
1. Busch W: Die Morphologie der Sella turcica
und ihre Beziehungen zur Hypophyse. Virchows
Arch Pathol Anat 1951;320:437-458.
2. Brismar K, Efendic S: Pituitary function in
the empty sella syndrome. Neuroendocrinology
1981;32:70-77.
3. Kaufman B: The 'empty' sella turcica: A
manifestation of the intrasellar subarachnoid
space. Radiology 1968;90:931-941.
4. Bjerre P, Gyldensted C, Riishede J, et al:
The empty sella and pituitary adenomas: A theo-
ry on the causal relationship. Acta Neurol Scand
1982;66:82-92.
5. Davis S, Tress B, King J: Primary empty
sella syndrome and benign intracranial hyper-
tension. Clin Exp Neurol 1978;15:248-257.
6. Moretti G, Manzoni GC, Mainini P, et al:
Empty sella headache. Headache 1981;21:211\x=req-\
217.
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is of moderate intensity, chronic,
asymmetrical, and anterior. Most
authors feel these headaches are too
nonspecific to be of diagnostic value.
Since patients with headaches are
more likely to be evaluated with sinus
and skull films, this association of
headaches and ESS might be consid¬
ered one of selection. Moretti et al,6
however, think that the high inci¬
dence of headache in patients with
ESS suggests more than a coinciden¬
tal relationship. In addition, they feel
there are several characteristics of
the ESS headache that can distin¬
guish it from other common headache
syndromes. Notably, the headaches
usually lack the family history and
related phenomena of migraines such
as aura, nausea, and vomiting. Unlike
the common tension headache, the
empty sella headache is frequently
unilateral and anterior. Pathogenical-
ly, the headache has been postulated
to arise secondary to traction on pain-
sensitive vascular-meningeal struc¬
tures in the sellar cavity. On occasion,
the headache has been relieved follow¬
ing surgical exploration of an empty
sella.14
When evaluating the patient com¬
plaining of headaches, ESS should be
considered a possible cause when
there is roentgenographic evidence of
an enlarged sella, the lack of head-
References
7. Bergerson C, Kovacs K, Bilbao JM: Primary
empty sella: A histologic and immunocystologic
study. Arch Intern Med 1979;139:248-249.
8. Jordan RM, Kendall JW, Kerber CW: The
primary empty sella syndrome. Am J Med
1977;62:569-580.
9. Spaziante R, de Divitiis E, Stella L, et al:
The empty sella. Surg Neurol 1981;16:418-426.
10. Ekblom M, Ketoner L, Kuuliala I, et al:
Pituitary function in patients with enlarged sella
turcica and primary empty sella syndrome. Acta
Med Scand 1981;209:31-35.
11. Dominque JN, Wing SE, Wilson CB: Coex-
isting pituitary adenomas and partially empty
sellas. J Neurosurg 1978;48:23-28.
12. Neelon FA, Goree JA, Lebovitz HE: The
primary empty sella: Clinical and radiographic
characteristics and endocrine function. Medicine
1973;52:73-92.
ache-related physical findings, and a
history consistent with the syndrome.
The diagnosis is confirmed by high-
resolution CT scanning, which demon¬
strates an enlarged sella containing
material of equal density to CSF. The
false impression of an empty sella can
be created by a partial volume effect
inpatients with a hyperpneumatized
sphenoid sinus or dilated perisellar
CSF spaces.9 In questionable cases,
intrathecal metrizamide may be nec¬
essary to further demonstrate the
herniated subarachnoid space.15,16
Generally, ESS is a benign condi¬
tion with a good prognosis; neverthe¬
less, it is the clinician's responsibility
to rule out an intrasellar neoplasm.
Equally as important, however, is the
follow-up of these patients. Although
uncommon, the possible development
of visual field disturbances and pitu¬
itary function abnormalities necessi¬
tates periodic examinations. Any sig¬
nificant change in the headache pat¬
tern or intensity, endocrine function,
visual field deficits, or the develop¬
ment of rhinorrhea should alert the
clinician to reevaluate the patient for
possible complications of ESS. Until
that time, symptomatic treatment of
the headache should be the primary
mode of therapy.912 Methods of surgi¬
cal therapy, although implied, have
not been directly addressed.914
13. Jaffer KA, Obbens EA, El Gammal TA:
'Empty' sella: Review of 76 cases. South Med J
1979;72:294-296.
14. Laws ER, Ebersold MJ, Kern EB, et al: The
results of transsphenoidal surgery in specific
clinical entities, in Laws ER, Randall RV, Kern
EB, et al (eds): Management ofPituitary Adeno-
mas and Related Lesions With Emphasis on
Transsphenoidal Microsurgery. New York,
Appleton-Century-Crofts, 1982, pp 277-305.
15. Sage MR, Chan E, Reilly PL: The clinical
and radiological features of the empty sella
syndrome. Clin Radiol 1980;31:513-519.
16. Price MJ, Corbett J, Thompson HS: Diag-
nosis of the empty sella with intrathecal metri-
zamide computed tomography. Surv Ophthalmol
1983;28:42-44.