Asymptomatic Empty Sella: A Literature Review and Suggestions for Evaluation in Clinical Practice

Empty sella (ES) is a radiographic finding defined by the presence of cerebrospinal fluid in the sella turcica, with associated compression of the pituitary gland. Empty sella syndrome (ESS) is the combination of this radiographic finding with endocrine, ophthalmological, and/or neurological symptoms. The focus of this literature review is to synthesize information about asymptomatic or incidental ES specifically, meaning the radiologic finding of an empty sella without symptoms. This condition is typically discovered incidentally through imaging when patients present with unrelated pathologies. Our intention is to strengthen the existing body of work on this clinical presentation and call for a standardized management protocol of ES. This literature review was performed in concordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). Data were extracted on paper characteristics, epidemiology, diagnostics, management, and outcomes. Overall, patients with radiographic findings of ES have a good prognosis. The majority of patients never become symptomatic (progression to ESS), and if symptoms do arise, they usually have little impact on quality of life. However, despite its inherent asymptomatic nature, given ES's estimated prevalence within society, the possibility of a critical underlying pathology, and the potential for subsequent development of consequential symptoms, this paper calls for the implementation of a standardized management protocol. We suggest that all patients with this finding and an unidentified underlying etiology, at a minimum, receive an endocrine panel for evaluation of pituitary function and a referral to ophthalmology for formal assessment of papilledema. We then recommend tailored management and referrals based on the results of these evaluations, as well as treatment of any subsequent symptomatology. While these are our recommendations based on a thorough review of the literature, further studies are necessary to reach a consensus on best clinical practices.