Perilymph Fistula in Emergency Medicine
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A perilymph fistula (perilymphatic fistula [PLF], labyrinthine fistula) is a pathologic communication between the fluid-filled space of the inner ear and the air-filled space of the middle ear, most commonly occurring at either the round or oval window. [1] The primary manifestations of perilymph fistulization are sudden or progressive fluctuating sensorineural hearing loss and vertigo. Other symptoms that may be present include tinnitus, disequilibrium, and aural fullness.
This clinical entity was proposed more than a century ago, yet it remains a topic of controversy, especially regarding the occurrence of spontaneous perilymph fistula (PLF). Trauma and poststapedectomy are etiologies proven to cause PLFs and must be considered in the appropriate settings. A PLF should be considered in pediatric patients with recurrent meningitis, and the option of middle ear exploration should be pursued. It is likely that most pediatric patients with PLFs will have an anatomic abnormality of their middle ear or labyrinth. It is also known that although several potential pathways exist between the perilymphatic space and the middle ear, actual leaking of fluid can be difficult or impossible to prove.
There is no agreed upon diagnostic test with enough sensitivity and specificity to identify the presence or absence of perilymph fistula. This has made it difficult to establish criteria to determine when surgical exploration might be indicated. Additionally, there are no universally accepted criteria to confirm diagnosis at surgery; the determination of the presence or absence of PLF is the subjective decision of the surgeon. Additionally, the presence of clear fluid in the middle ear at the time of surgery may represent perilymph or may be CSF, serum, or local anesthetic. No reliable and accurate test is currently available to reliably distinguish these fluids from one another. No studies have been reported to account for the substantial placebo effect of a surgical procedure for vertiginous symptoms in patients with suspected PLF, and no appropriate long-term follow up of patients after surgery has been reported.
The presenting complaint and symptoms of perilymph fistula are often consistent with Meniere syndrome. Therefore, in the absence of prior surgery or definite traumatic event, distinguishing a perilymph fistula from Meniere syndrome may be difficult.
Most commonly, a tear in the round or oval window leads to loss of perilymph into the middle ear. This condition may be the result of stapes prosthesis surgery, trauma, barotrauma, or bony erosion due to infection or neoplasm, or it may be idiopathic. Markou et al reported on a patient who developed a perilymph fistula in the round window due to a whiplash injury. [2] In children, perilymph fistulas are associated with congenital anomalies of the middle or inner ear.
In children, the condition may be associated with recurrent meningitis. Acute or chronic perilymph fistulas may significantly affect quality of life.
Prevalence of perilymph fistula is higher in females than in males.
Perilymph fistulas occur in young children with congenital abnormalities; otherwise, the condition is not known to be age specific.
Al Felasi M, Pierre G, Mondain M, Uziel A, Venail F. Perilymphatic fistula of the round window. Eur Ann Otorhinolaryngol Head Neck Dis. 2011 Jun. 128(3):139-41. [Medline].
Markou K, Rachovitsas D, Veros K, Tsiropoulos G, Tsalighopoulos M, Psillas G. Perilymphatic fistula of the round window after whiplash injury: another cause of inner ear conductive hearing loss. Am J Otolaryngol. 2014 Nov-Dec. 35 (6):822-5. [Medline].
Haubner F, Rohrmeier C, Koch C, et al. Occurence of a round window membrane rupture in patients with sudden sensorineural hearing loss. BMC Ear Nose Throat Disord. 2012 Nov 29. 12:14. [Medline]. [Full Text].
Ikezono T, Shindo S, Sekiguchi S, Hanprasertpong C, Li L, Pawankar R, et al. Cochlin-Tomoprotein: A Novel Perilymph-Specific Protein and a Potential Marker for the Diagnosis of Perilymphatic Fistula. Audiol Neurootol. 2009 Apr 15. 14(5):338-344. [Medline].
Ikezono T, Shindo S, Sekine K, Shiiba K, Matsuda H, Kusama K, et al. Cochlin-tomoprotein (CTP) detection test identifies traumatic perilymphatic fistula due to penetrating middle ear injury. Acta Otolaryngol. 2011 Sep. 131(9):937-44. [Medline].
Bruzzone MG, Grisoli M, De Simone T, Regna-Gladin C. Neuroradiological features of vertigo. Neurol Sci. 2004 Mar. 25 Suppl 1:S20-3. [Medline].
Nancy E Conroy, MD Clinical Assistant Instructor, Staff Physician, Department of Emergency Medicine, SUNY Downstate Medical Center/Kings County Hospital Center, Brooklyn
Nancy E Conroy, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Medical Society of the State of New York, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Mert Erogul, MD Assistant Professor of Emergency Medicine, University Hospital of Brooklyn; Consulting Staff, Department of Emergency Medicine, Kings County Hospital
Mert Erogul, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Steven C Dronen, MD, FAAEM Chair, Department of Emergency Medicine, LeConte Medical Center
Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Jerry R Balentine, DO, FACEP, FACOEP Vice President, Medical Affairs and Global Health, New York Institute of Technology; Professor of Emergency Medicine, New York Institute of Technology College of Osteopathic Medicine
Jerry R Balentine, DO, FACEP, FACOEP is a member of the following medical societies: American College of Emergency Physicians, New York Academy of Medicine, American College of Osteopathic Emergency Physicians, American Association for Physician Leadership, American Osteopathic Association
Disclosure: Nothing to disclose.
Mark W Fourre, MD Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine; Program Director, Department of Emergency Medicine, Maine Medical Center
Disclosure: Nothing to disclose.
Perilymph Fistula in Emergency Medicine
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