INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)

ISSN No. 2321-2705 | DOI: 10.51244/IJRSI |Volume XII Issue VIII August 2025

Page 1860

www.rsisinternational.org

Primary empty sella syndrome (ESS) is characterized by herniation of the subarachnoid space into the sella

turcica with pituitary flattening. While usually asymptomatic, primary ESS can rarely present with

cerebrospinal fluid (CSF) rhinorrhea.

We report the case of a 67-year-old man with a 3-month history of headache and left-sided clear nasal

discharge. Neurological and ophthalmological examinations were normal. Brain magnetic resonance imaging

(MRI) revealed an empty sella. Endocrinological tests were within normal limits. An endoscopic transnasal

transsphenoidal repair was performed using autologous fat grafting, resulting in complete resolution of

symptoms. CSF leaks in ESS are often attributed to elevated intracranial pressure and diaphragmatic

incompetence, leading to sellar floor erosion. Endoscopic repair offers a minimally invasive approach with

Empty sella syndrome (ESS) is defined by the herniation of the subarachnoid space into the sella turcica with

flattening of the pituitary gland, as first described by Busch in 1951. It is classified as primary or secondary.

While the secondary form is known to be due to a tumor, surgery, radiation therapy or any harmful event

leading the pituitary gland to shrink and disappear on imaging causing frequent pituitary hormonal

dysfunction, the primary form typically arises in the context of congenital diaphragmatic weakness and

elevated intracranial pressure and is often asymptomatic. It may rarely present with CSF rhinorrhea,

representing a significant risk of meningitis.

We report the case of a 67-year-old male patient with primary ESS complicated by CSF rhinorrhea,

successfully treated by endoscopic transnasal transsphenoidal repair.

Case Report

grafting and reinforced with fibrin glue. Postoperative recovery was uneventful, with complete resolution of

symptoms at follow-up.

INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)

ISSN No. 2321-2705 | DOI: 10.51244/IJRSI |Volume XII Issue VIII August 2025

Page 1861

www.rsisinternational.org

Spontaneous CSF leak is common. In case of empty sella, the elevated intracranial fluid pressure results in

bone thinning in sphenoid sinus and cribriform plate [3]. It may eventually cause brain herniation or bone

erosion with CSF leakage. Number of hypotheses may explain the cause of primary ESS [4]. A reasonable

explanation is that the condition arises in a patient who has an elevation in intracranial pressure associated with

an incompetent diaphragma sella which allows the subarachnoid space to be forced into the sella by the

hydrostatic pressure and pulsatile movement of CSF. The bony erosion, especially if augmented by increased

intracranial pressure, can cause communication of the intrasellar subarachnoid space with the sphenoid sinus.

CSF. Because of the high risk of CSF rhinorrhea and infection, the intradural technique was replaced by the

extradural technique which represents the current treatment modality [4,6]. Several materials have been

suggested for filling the sellar space and reconstruction of the sellar floor. As recorded by many authors, the fat

was prefered over muscle because it results in less necrosis or scar retraction over time [4]. The technique

consists of inserting an amount of fat inside the sella which will push the optic structure into their normal

position. Extradural transsphenoidal chiasmapexy can be indicated if the optic chiasm herniated inside the sella

causing progressive visual abnormalities [7]. They include muscle, fat, dural substitutes, cartilage, bone

fragments, ceramic substances and titanium plates.

The endoscopic approach is considered the preferred procedure for treatment of sinus CSF leaks [6,8]. The

success rate is estimated between 90 and 95%. It is associated with less complication than the open skull

INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)

ISSN No. 2321-2705 | DOI: 10.51244/IJRSI |Volume XII Issue VIII August 2025

Page 1862

www.rsisinternational.org

Patient Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying

images.

Fig 1: Brain MRI sequences in axial (a), sagittal (b) and coronal (c) sections show the intrasellar

arachnoidocele