Keywords

• perilymph fistula
• case report
• hearing loss
• vertigo
• barotrauma
• fistula test
• surgical repair

Case Presentation

A 34-year-old female presented with a three-week history of episodic vertigo and fluctuating hearing loss in the left ear. She reported an acute onset of symptoms after a forceful sneeze while straining to lift a heavy object. There was no history of head injury, ear surgery, or chronic ear disease. Otoscopy revealed normal tympanic membranes bilaterally.

Clinical Findings

Pure-tone audiometry demonstrated a mild-to-moderate sensorineural hearing loss in the left ear, with a high-frequency component. Tympanometry was normal. The patient experienced reproducible vertigo and nystagmus when positive pressure was applied to the left external auditory canal using a pneumatic otoscope, a finding suggestive of a perilymph fistula. No spontaneous nystagmus was observed at rest. Vestibular evoked myogenic potentials showed reduced amplitudes on the affected side.

Diagnostic Workup

High-resolution computed tomography of the temporal bones was unremarkable, showing no obvious bony dehiscence or abnormality of the oval or round windows. Magnetic resonance imaging with intratympanic gadolinium was considered, but the patient declined further imaging. Based on the history of barotrauma, the presence of a positive fistula test, and characteristic audiovestibular symptoms, a clinical diagnosis of probable perilymph fistula was made.

Management and Outcome

The patient was initially managed with strict bed rest, head elevation, and avoidance of straining, coughing, and heavy lifting. However, her symptoms persisted despite two weeks of conservative treatment. She subsequently underwent surgical exploration of the left middle ear under local anesthesia with sedation. A small leak of clear fluid was identified at the anterior margin of the oval window. A tissue graft was placed over the fistula site and secured with fibrin sealant.

Postoperatively, the patient reported immediate resolution of vertigo. She experienced gradual improvement in hearing over the following weeks. Audiometry performed two months after surgery showed near-complete recovery of hearing thresholds in the low and middle frequencies, with a residual mild high-frequency loss. At six-month follow-up, she remained symptom-free and had returned to normal activities.

Discussion

A perilymph fistula is an abnormal communication between the inner ear and the middle ear, typically at the oval or round window, resulting in leakage of perilymph. Common causes include head trauma, barotrauma (as in this case), exertion, or iatrogenic injury. Symptoms often include sudden or fluctuating hearing loss, vertigo, disequilibrium, and a sensation of aural fullness. The clinical presentation can be highly variable, making diagnosis challenging.

The fistula test is a valuable bedside diagnostic tool, although a negative result does not exclude the condition. Imaging studies may be helpful in identifying gross abnormalities, but they are often non-diagnostic. Definitive diagnosis is frequently made by surgical exploration of the middle ear. Conservative management with activity restriction may be sufficient for some patients, but surgical repair is often required for those with persistent symptoms or progressive hearing loss. Prompt recognition and treatment are important to preserve auditory function and alleviate vestibular symptoms.