EMPTY SELLA SYNDROME V. follow up management

Aquino, Felix SP
Sarmiento, Noel

EMPTY SELLA SYNDROME

V. Follow-up management

Medical follow-up is recommended to monitor patient health status, effectiveness of treatment and if there is complication develop from empty sella syndrome. Primary empty sella syndrome does not have adverse health consequences, and it does not alter life expectancy. However, the specific cause of pituitary gland injury and the effects of hypopituitarism contribute to the outcome with secondary empty sella syndrome. (Melmed et al, 2008)

Non-symptomatic cases require no treatment but periodic follow up is necessary. Patients with no abnormalities at baseline are unlikely to develop neuro-/ophthalmological symptoms or endocrine abnormalities in the follow-up. (Marinis et al, 2005) Moreover, also the radiological degree of PES tends to remain constant over time. However, because of the theoretical risk of progression, a reevaluation after 24–36 months (if there are not clinical indications before) of the endocrine, neuro-/ophthalmological and radiological picture is reasonable. If progression is not observed, additional control evaluation could be even less frequent and limited to those patients requiring it clinically.

In patients with confirmed empty sella and manifest symptoms of hypopituitarism, cerebrospinal fluid (CSF) rhinorrhea, visual disturbance and increased intracranial pressure, follow up is mandatory for the management of symptoms and prevention of complications that it may bring (Kim et al,2009).

Empty sella is associated with neuroradiological and endocrine symptoms. Patients with PES should always submit endocrine, neurological, and ophthalmological evaluation at presentation because of the very high incidence of these abnormalities.
Patients treated medically for any endocrine abnormalities should be reevaluated according to appropriate well-established guidelines. Endocrine screening should be followed by specific endocrine testing when hormonal abnormalities are suspected. This procedure is able to detect all the affected patients with a very low number of unconfirmed diagnoses.
Patients treated surgically should also be reevaluated for assessing long-term results and side effects at least twice in the year after surgery. Indications for surgical treatment of empty sella are CSF rhinorrhea, because of the risk for meningitis, visual disturbance, and severely increased intracranial pressure.

Moreover, patients treated for idiopathic intracranial hypertension should receive follow-up imaging study. Magnetic resonance imaging study will show if there is a positive response to therapy and possibly denote a corresponding decrease in intracranial pressure. (Zagardo et al, 2006).

Furthermore, patients diagnosed of empty sella syndrome with visual disturbance should pay attention on intraocular pressure measurement, and optic disc and visual field patterns on follow up visits. (Jenjit et al, 2009).

Moreover, according to Elias (2005), seven-eighths of empty sella syndrome patients suffer from coexisting glaucoma, which is readily treatable. Clearly, conservative treatment requires close medical and ophthalmologic follow-up.
As a nurse, it is our duty to provide adequate information and instruction to the patient suffering from empty sella syndrome and his family. This will enable them to be a part of care through monitoring patient’s condition and response therapy, if there is. The need for a multidisciplinary approach and close follow-up of patients with an empty sella and functional deficits should be emphasized. (Komada et al, 2009)

Patient and family should be instructed that prompt reporting of new symptoms is important in addition to routine follow-up visits is a must. If patient develops symptoms of abnormal pituitary function, such as a disrupted menstrual cycle or impotence, a need to contact his physician must be done for prompt test and treatment. (New York Times, 2010) However, If the patient has no new symptoms or problems beyond about 5 years after beginning treatment, follow-up visits can be less frequent.

Due to visual disturbances, patient is high risk for injury (Answer.com, 2010). Patient’s relative should be advice to assist patient in moving and attending self-care to promote safety of the patient.

Patients with CSF rhinorrhea should be instructed to maintain at bed rest in a semi-sitting Fowler position. (Robertson, 2009). They should be instructed to avoid sneezing or coughing, since these actions increase the intracranial pressure and favor persistence of the CSF leak.

In conclusion, patient diagnosed of empty sella syndrome with or without symptoms should attend follow-up visits with his physician. Follow-up visits primarily will aid in monitoring patient health status, development in the prescribed treatment, and to avoid complications

Reference:

Answer.com. (2010).Empty sella syndrome. Retrieved on February 16, 2010 at http://www.answers.com/topic/empty-sella-syndrome

Elias, M. (2005). Empty sella syndrome. Retrieved on February 14, 2010 at http://pituitaryadenomas.com/emptysella.htm

Jenjit Choovuthayakorn, J., Changwiwit, R., Navacharoen, W., & Wattananikorn, S. (2009). Case Reports : Visual Field Defect in Primary Empty Sella Syndrome. Retrieved on February 19, 2010 at www.rcopt.org/2009/download/05-10.pdf

Kim, J., Ko, J., Kim, J., Ha, H., Jung, C. (2009). Analysis of Empty Sella Secondary to the Brain Tumors.Journal Korean Neurosurgeon Society.

Komada H, Yamamoto M, Okubo S, Nagai K, Iida K, Nakamura T, Hirota Y, Sakaguchi K, Kasuga M, Takahashi Y. (2009).A case of hypothalamic panhypopituitarism with empty sella syndrome: case report and review of the literature. Retrieved on February 19, 2010 at http://www.ncbi.nlm.nih.gov/pubmed/19352054?ordinalpos=1&itool=Entrez System2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_SingleItemSupl.Pubmed_Discovery_RA&linkpos=5&log$=relatedreviews&logdbfrom=pubmed

Marinis L., et al,.( 2005).Extensive Clinical Experience: Primary Empty Sella.J Clin Endocrinol Metab, 90(9):5471–5477

Melmed S, Kleinberg D. (2008). Anterior pituitary. In: Kronenberg HM, Melmed S, Polonsky KS, Larsen PR, eds. Williams Textbook of Endocrinology. Philadelphia, PA: Saunders Elsevier;

Robertson, H. (2009). Cerebrospinal Fluid, Leak: Follow-up. Retrieved on February 19, 2010 at http://emedicine.medscape.com/article/338989-followup
The New York Times.(2010).Retrieved on February 19, 2010 at http://health.nytimes. com/health/guides/disease/empty-sella-syndrome/overview.html

Zagardo, M., Cail, W.,Kelman, S., & Rothman, M. (2006). Reversible Empty Sella in Idiopathic Intracranial Hypertension: An Indicator of Successful Therapy? Retrieved on February 19, 2010 at www.ajnr.org/cgi/reprint/17/10/1953.pdf









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