in the name of god - tums.ac.ir fistula.pdf · perilymphatic fistula dr. sasan dabiri...
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In the name of God
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Perilymphatic Fistula
Dr. Sasan DabiriOtorhinolaryngologist – Head & Neck Surgeon
January 2010Imam Hall – Imam Khomeini Hospital Complex
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• Abnormal connection between
fluid-filled inner ear &
gas-filled middle ear
• First time recorded at 1897
• One of the most challenging topics in otolaryngology
PerilymphaticFistula
Definition
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• Congenital / Developmental
• Trauma– Direct
• Surgery• Blow
– Indirect• Exertion (lift,…)• Blow• Barotrauma
PerilymphaticFistula
Definition
Etiology
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• Vestibular disturbances the most prevalent complaint
• Hearing disturbances usually fluctuant• sudden loss
• rapidly progressive
• Tinnitus isolated is not seen
• Aural fullness
PerilymphaticFistula
Definition
Etiology
Clinical Finding
Most patients have combination
of symptoms
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Most children with sudden or progressive SNHL have suffered from
cochlear diseases other than perilymphatic fistula
• hereditary progressive loss
• viral labyrinthitis
• autoimmune inner ear disease
• endolymphatic hydrops
PerilymphaticFistula
Definition
Etiology
Clinical Finding
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Even in the situation of highest suspicion
(sudden loss triggered by head trauma in a child with radiographically malformed inner ears)
only a minority of patients demonstrate window fistulization
Many of these children have internal fistulization
PerilymphaticFistula
Definition
Etiology
Clinical Finding
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• History
• Physical Examination• Fistula test
• Paraclinic Examination• Audiometry (PTA & SDS)
• Electrocochleography (ECoG) ?
• Electronystagmography (ENG) ?
• Perilymph leak assay• Volume of perilymph : 0.075 ml
• Rarely dramatic leak
PerilymphaticFistula
Definition
Etiology
Clinical Finding
Diagnosis
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• Exploration
– Seen by at least to surgical personnel
– Shift in light reflex
– Trendelenburg position
– Valsalva
– Internal Jugular vein compression
– Drop of mineral oil
Positive exploration rate: 55%
PerilymphaticFistula
Definition
Etiology
Clinical Finding
Diagnosis
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• Exploration
• Endoscopy
• first in 1967
• Variability in observing fistula– Observer bias
– Mistaken of fluid
– Fluctuant nature of leak
PerilymphaticFistula
Definition
Etiology
Clinical Finding
Diagnosis
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• Exploration
• Endoscopy
• Fluorescein Intratechal
o Neurologic complications
Intravenous
o Mixture of blood & perilymph
Labeled anesthetics
PerilymphaticFistula
Definition
Etiology
Clinical Finding
Diagnosis
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• Exploration
• Endoscopy
• Fluorescein
• Electrophoresis
Protein concentration
CSF: 20 mg/dL Perilymph: 200 mg/dL Serum: 7000 mg/dL
risk of dilution
PerilymphaticFistula
Definition
Etiology
Clinical Finding
Diagnosis
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• Exploration
• Endoscopy
• Fluorescein
• Electrophoresis
Protein concentration
Specific protein
•Beta 2 transferrin•Apolipoprotein D•Beta tace protein
(PG D synthase)
must be pure & concentrated
PerilymphaticFistula
Definition
Etiology
Clinical Finding
Diagnosis
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• Exploration
• Endoscopy
• Fluorescein
• Electrophoresis
• Imaging (CT or MR)
Intratechal contrast may be useful Pneumolabyrith is highly suggestive
PerilymphaticFistula
Definition
Etiology
Clinical Finding
Diagnosis
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Intervention or Observation?
This is a question.
PerilymphaticFistula
Definition
Etiology
Clinical Finding
Diagnosis
Management
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• Bed rest
• Head elevation
• Stool softeners
• Avoidance of straining, coughing, or sneezing
no reports of the percentage of response
PerilymphaticFistula
Definition
Etiology
Clinical Finding
Diagnosis
Management
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• Grafting of the oval and round windows
• Areolar tissue coforms best to windows
• Perichondrium is better than fat
• Fat with Higher recurrence
• Fascia may be disappeared
Improvement of adhesion with
Fibrin glue or Laser coagulation
PerilymphaticFistula
Definition
Etiology
Clinical Finding
Diagnosis
Management
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Difficult outcome analysis because of range of complaints at initial
• Relief of vertigo: quite good (75 – 100%)
although spontaneous recovery from vestibulopathy is common in pediatrics
• Relief of hearing loss:more frustrating
– 50% of patients: improved hearing
– 25% of patients: SRT>35 dB or SDS>80%
PerilymphaticFistula
Definition
Etiology
Clinical Finding
Diagnosis
Management
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Vestibular symptoms are the most &
Hearing loss are usually fluctuant and is sudden or rapidly progressive
Attention to more common DDx such as ménière
There is not diagnostic study
Diagnosis is based on constellation of clinics & paraclinics & sometimes exploration
Can be surgical or medical, but superiority of either is not documented
PerilymphaticFistula
Definition
Etiology
Clinical Finding
Diagnosis
Management
Conclusion
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•Special Thanks for Your Attention