|Year : 1983 | Volume
| Issue : 5 | Page : 581-584
Evaluation of cases of enlarged sella
D Roy Choudhury, M Bhattacharjee, KK Chatterjee, Ranabir Mukherji
Neuro-ophthalmological Clinic, Deptt. of Ophthal., Calcutta National Medical College, Calcutta, India
D Roy Choudhury
Neuro-ophthalmological Clinic, Deptt. of Ophthal., Calcutta National Medical College, Calcutta
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Choudhury D R, Bhattacharjee M, Chatterjee K K, Mukherji R. Evaluation of cases of enlarged sella. Indian J Ophthalmol 1983;31:581-4
|How to cite this URL:|
Choudhury D R, Bhattacharjee M, Chatterjee K K, Mukherji R. Evaluation of cases of enlarged sella. Indian J Ophthalmol [serial online] 1983 [cited 2019 Aug 23];31:581-4. Available from: http://www.ijo.in/text.asp?1983/31/5/581/36595
The enlargement of Sella is the most common finding detected in routine neuroophthalmological investigations. Though sellar tumours, particularly pituitary adenoma is frequently blamed for the condition, the enlargement of sella may result from host of other conditions as well. During the period from January, 1972 to June, 1981, in 76 patients of the Neuro-ophthalmological clinic at the Calcutta National Medical College & Hospital plain X-ray of the skull revealed in the lateral view, enlargement of the Sella. Any Sella with a depth of over 15 mm and AP diameter of over 20 mm have been taken as abnormal. The age and sex distribution of these patients were as follows: [Table - 1]
The chief presenting symptoms were -
a) Visual defect in all the 76 cases.
b) Vomiting in 59 cases.
c) Double vision in 11 cases.
On clinical examination, the following signs were detected -
i) Long tract signs - 26 cases.
ii) Cerebellar sign - 19 cases.
iii) Other cranial nerves involvement - 35 cases.
a) VI - 18 Papilloedma in 30 cases.
b) VII - 7 Pallor of disc in 35 cases.
c) III & VI- 4
d) Lower cranial nerves -- 6
iv) Acromegaly - 6
All the cases who came to the Clinic were routinely examined for ophthalmological features.
All the cases were examined for the ocular movements, pupillary reaction, vision and fundus. Field of vision could not be taken in all the cases.
Lagophthalmos was seen in 7 cases on one side only. Ocular movements were restricted in 18 cases due to 3rd and 6th nerve involvement. In 4 cases involvement was seen in both eyes, and in 14 cases it was unilateral. Nystagmus was seen in 15 cases. In 19 cases other cerebellar signs were noticed. Pupillary reactions were normal in (direct consensual and accommodation) 60 cases. In two cases one pupil was dilated and immobile. In other 14 cases pupillary reactions were sluggish.
Visual defects were noted in all cases. Slight defect ranging from 6, 6 part to 6/ 12 in 41 cases (including normal fundus and papilloedema).
In two cases in one eye vision was only perception of light and the other eye 6/18 and 6124.
In remaining cases (33 cases) vision was 6/36 to 6,18 (marked loss of vision was noted with pale disc with shallow cupping).
Out of 76 cases, 11 patients had normal fundus. 30 cases had papilloedema. It includes slight congestion of the disc to oedema upto 7 diopter.
In two cases there was oedema of the disc with pallor of the other. In 35 patients both discs were pale. Amongst 35 patients, 10 cases had pale disc with shallow cupping.
Field of vision (perimetry and scotometry)
Only 40 patients were examined for field of vision. Most of the patients were dull or nonco-operative. Scotometary was more difficult. In ten cases there was bitemporal quadrantopia.
In 4 cases there was bitemporal hemianopia. In two cases there was almost complete loss of vision in one eye and temporal hemianopia in other eye. In other cases there was concentric contraction with defect in the temporal field (in two cases there was homonimous hemianopia with concentric loss).
In scotometry there were 5 cases of classical bitemporal hemianopic central field with macular spare. Other cases only revealed enlargement of blind spot.
Straight X-ray of skull revealed enlargement of sella in 76 cases. Additional findings were sutural diastasis in 18 cases. Abnormal calcification in 9 cases and silver beaten appearance in all cases.
Typical balloning of sella was seen in only 18 cases, enlargement of sella with destruction of clinoid process in 8 cases, only slight enlargement in 25 and slight enlargement with post clinoid destruction in 25 cases.
This was performed in all cases of this series. In 15 patients shift of mid-line echo was evident helping us in lateralisation of lesion.
In 60 cases this investigation was carried out of which in 12 cases there were definite abnormalities to help in the localisation of lesion.
3. Invasive investigations
18 patients did not agree to undergo invasive investigations.
a) Carotid angiography
In 58 patients this investigation was done after admission in the hospital. In 22 patients this procedure along with clinical assessment and Echo and E.E.G. findings were adequate in localising the lesion. In 36 cases following investigations (either one or more than one) were also performed to arrive at a diagnosis.
b) Pneurnoencephalography - 12
c) Conray ventriculography - 16
d) Isotope Brain Scan - 12
e) C T Scan - I (done in New Delhi)
With all these investigations in 42 cases definite diagnosis could be made and in 16 cases diagnosis was only tentative.
27 cases were operated for primary pathology causing enlargement of Sella.
1. Pituitary tumour - 15 -19
Craniopharyngioma - 4 - 19
2. Paraventricular astrocytoma - 4
3. Supratentorial meningioma - 2
4. Cerebellar tumour - 2
Enlargement of ventricular system was evident in 21 cases and V.A. shunt was done in these cases with amelioration of clinical features.
10 cases who did not agree to undergo operation the diagnosis was posterior fossa lesion in 3 cases, internal hydrocephalus of undetermined etiology-5 cases and deep seated S.O.L.-2 cases.
18 patients, who did not submit to invasive investigations clinical diagnosis were pituitary tumour-8, craniopharyngioma-2, internal hydrocephalus-4 and in 4 cases cause for enlargement of sella could not be ascertained.
| Discussion|| |
In this series, taking all cases together, enlargement of sella due to ventricular enlargement was seen in 25 cases, pituitary tumour and craniopharyngioma in 29 cases and other intracranial pathology constituted 22 cases.
Ballooning of sella was classical of pituitary tumour and was evident in all cases. Presence of supra sellar calcification was seen in 2 out of 6 cases of craniopharyngioma. Destruction of clinoid process or slight enlargement of sella with other evidences of raised intracranial tension speak in favour of ventricular enlargement or other intracranial pathology.
The papilloedema, as expected was conspicuous by its absence in all cases of pituitary tumours. In one of our cases of craniopharyngioma, papilloedema was observed, possibly due to distortion of ventricular system.
Cranial nerve palsy was a pointer that the pathology was other than sellar tumour.
Endocrine dysfunction though common in pituitary tumour (16 out of 29 cases), was also observed in another 13 cases where enlargement of sella was due to ventricular dilatation. In late cases (as we usually accustomed to see), it would be difficult to differentiate the various causes of sellar enlargement from endocrine study.
The visual acuity and the fields of vision commensurated with the pathological changes taking place in the chiasma and visual pathway by the primary condition.
| Summary and Conclusion|| |
76 cases of enlarged sella have been investigated. Most of them were late cases and incidences of a) sellar pathology, b) ventricular enlagement and c) other causes of raised intracranial tension were very close (29: 25: 22). Complete investigations are essential to arrive at a diagnosis. Ophthalmological findings have been analysed and their importances have been stressed. In late cases endocrine dysfunction due to non-sellar tumour is also high. C T Scan is essential in all neuroophthalmological cases for easy and definitive diagnosis but in this series, C T Scan could be done in one case only. 41 cases needed invasive investigation for definite diagnosis and in the remaining cases diagnosis was only tentative.
[Table - 1]