Three weeks after stapes surgery a 41-year-old man reports vertigo induced by straining and by loud noises, along with fluctuating sensorineural hearing loss. Pressure applied over the tragus reproduces his dizziness despite an intact tympanic membrane. The most likely diagnosis and definitive management are:

• A Posterior canal BPPV managed with the Epley manoeuvre
• B Superior canal dehiscence managed with endolymphatic sac decompression
• C Labyrinthitis managed with corticosteroids
• D Perilymph fistula managed with exploratory tympanotomy and tissue patch repair ✓

Explanation

A positive fistula sign, meaning vertigo and nystagmus on tragal pressure or pneumatic otoscopy with an intact drum, plus sound induced vertigo after stapedectomy or barotrauma, points to a perilymph fistula, an abnormal communication between the middle and inner ear at the oval or round window. BPPV lacks a positive fistula test and hearing loss. Endolymphatic sac decompression treats Meniere's disease. Steroids treat inflammatory labyrinthitis, not a mechanical leak.

Reference: Dhingra, Diseases of Ear, Nose and Throat, 8th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.