Vertigo

The abrupt onset of vertigo after direct ear trauma such as a foreign body penetration into the ear canal should immediately prompt the diagnosis of perilymph fistula. Unfortunately such instances are rare, and more commonly, consideration of the diagnosis of perilymphatic fistula in patients with vertigo symptoms is more nonspecific. Attention to the nature of the vestibular symptoms along with onset, duration, frequency, and associated symptoms is helpful in establishing the differential diagnosis. Vertigo caused by a traumatic perilymph fistula occurs at the time of the injury and is abrupt and violent. Vertigo can last from minutes to hours and is often accompanied by nausea and vomiting. If the fistula closes, the usual recovery from the vestibular insult occurs over the next 6 to 8 weeks. Persistent vestibular symptoms after this time should alert the clinician to the possibility of a persistent or intermittent fistula. In most cases, the recurrent vertigo will not be as severe in duration as the initial injury. The vertigo is abrupt with a strong sense of rotation and at times falling, but usually lasts minutes with less severe vegetative symp toms. Vertigo attacks are often triggered by increased intracranial pressure and may be associated with hearing loss, tinnitus, or aural fullness. Positional vertigo to the side of the lesion is an interesting and unexplainable phenomenon that can occur with persistent perilymph fistula. This positional vertigo is not associated with increases of intracranial pressure and seems to develop as a chronic condition after the initial injury.

In addition to vertigo, the whole array of vestibular symptoms associated with varying degrees of vestibular compensation after an acute vestibular injury may be present in perilymph fistula. It is into this diagnostic miasma that some otologists fall, becoming charlatans at worst, and zealots at best, in over-diagnosing perilymphatic fistula in these chronic symptoms. Integral to entertaining the diagnosis of perilymph fistula in patients with these symptoms is an antecedent history of some type of trauma. Fluctuation or worsening of the symptoms with changes in intracranial pressure may also be confirmatory. Chronic lightheadedness or spatial disorientation alone are too vague to be used solely to entertain the diagnosis of perilymph fistula. Dysequilibrium that persists after severe vertigo, especially if associated with progressive hearing loss and tinnitus, may be caused by a perilymph fistula. Chronic nausea is at times a predominant symptom associated with such dysequilibrium.

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