Perilymphatic fistula repair

What Is a Perilymphatic Fistula?

A perilymphatic fistula (PLF) occurs when there is a tiny tear or defect in the oval window or round window—two thin membranes that separate the air-filled middle ear from the fluid-filled inner ear. The inner ear contains perilymph, a special fluid that helps transmit sound and maintain balance. When this fluid leaks, even in very small amounts, it disrupts the delicate pressure balance inside the inner ear. To learn more about PLFs, you can read this article.

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When Do We Consider Perilymphatic Fistula Repair? (Indications)

We begin to consider surgical repair when a patient has a combination of the following:

• Repeated episodes of sudden or fluctuating hearing loss combined with dizziness or imbalance. For a single episode, we usually prefer to monitor, as the diagnosis is not straightforward.
• Symptoms that worsen with pressure changes or physical exertion.
• A known triggering event (fall, head trauma, diving injury, rapid ascent in altitude, etc.) that preceded the onset of the symptoms. Some patients have "spontaneous" fistula, which means that there is no specific triggering event.  This condition is much less common, but in those patients we could consider surgical exploration even without a triggering event.   
• Clinical suspicion based on exam findings or testing patterns. 
  
  AND

• Persistent symptoms despite conservative treatment (rest, activity modification). The first step in someone with a suspected PLF is always conservative treatment. Only when that fails do we consider surgical treatment.   

A PLF can be difficult to confirm with absolute certainty before surgery. The decision often relies on a combination of symptoms, test results, and clinical judgment. 

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Pre-Operative Testing

Before recommending surgery, we perform a series of tests to assess hearing, balance, and how the inner ear is functioning. These tests, combined with your symptoms and history, help us determine whether a PLF is likely.

Audiogram

This hearing test measures how well you hear different tones and speech. In PLF, we often see sensorineural hearing loss (inner ear–related), which will commonly fluctuate. To learn more about audiograms, read this article.

Videonystagmography (VNG)

VNG evaluates your balance system by recording involuntary eye movements (nystagmus). It helps determine whether one inner ear is weaker than the other. The VNG is usually abnormal on the side of the fistula, indicating a problem in the inner ear, but can sometimes be normal. Read this article to learn more about VNGs.

vHIT (Video Head Impulse Test)

vHIT measures the vestibulo-ocular reflex (VOR), which keeps your vision stable when your head moves. Abnormalities can point to specific semicircular canal dysfunction related to the PLF. However, it can also be normal in patients with PLF. To learn more about vHITs, you can read this article.

VEMP (Vestibular Evoked Myogenic Potential)

VEMP testing measures how the inner ear responds to sound and vibration. It can detect subtle abnormalities in the balance organs. In some PLFs, VEMP responses may be reduced, absent, or unusually sensitive. You can learn more about VEMPs in this article.

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How Perilymphatic Fistula Repair Is Performed

PLF repairs are performed through the ear canal and can safely be done under local anesthesia with no sedation at all, or very light sedation. This avoids the risks associated with general anesthesia and allows faster recovery. More importantly, this allows me to talk to the patient, have him/her do a "Valsalva" maneuver while I look for the fluid lead.

 The entire procedure usually takes around 45 minutes. Here's a step-by-step explanation:

Step-by-Step Overview

1. Patient Preparation 

The patient lies on their back on the surgical bed with the head turned towards the non-operated ear (for example, if the surgery is on the left ear, the head will be turned to the right).  Mild sedation could be given at this point, and then the ear is frozen by injecting local anesthesia via a small needle. Once this part is done, the rest of the surgery is pain-free. The ear is then cleaned with an anti-septic solution to make the area sterile. Surgical drapes are then used to cover the head and body, leaving the ear exposed. 

2. Getting to the Middle Ear

A small incision is made within the ear canal (nothing on the outside), and the surgeon gently lifts the skin of the ear canal along with part of the eardrum (called a tympanomeatal flap). By raising the eardrum up (like a veil), we can get look inside the middle ear. This allows the surgeon to clearly see the oval and round windows, where the leak most commonly occurs.

3. Inspecting the windows

I visually examine the round window niche and the oval window. Sometimes a clear leak is visible, but often the defect is microscopic. To help expose the leak better,  I'll ask my patient to do a "valsalva maneuver", which involves bearing down forcefully or exhaling forcefully with the glottis (the throat) closed. This is why having the patient awake and cooperative in during the procedure is important. 

4. Sealing the suspected fistula

Tiny pieces of soft tissue — often from a perichondrial graft (thin fibrous tissue taken from the tragus, a small cartilage structure in front of the ear canal opening) — are used to form a plug over the round window and around the stapes footplate at the oval window. This helps reinforce the membrane and prevent further leakage. Even when the leak cannot be seen, symptoms and testing may justify sealing both sites.

4. Securing the graft

A small amount of blood or dissolvable packing (called gelfoam) will be used to keep the graft in place without applying pressure on the delicate inner ear structures.

5. Repositioning the eardrum

I place the eardrum back into its normal position and ensure it is in good condition. A small dissolvable dressing (gelfoam once again) will be used in the ear canal to keep the skin flap in place and ensure appropriate healing, and the rest of the ear canal will be filled with antibiotic ointment.

The entire procedure usually takes around 45 minutes.

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Post-Operative Care

Healing after PLF repair focuses on avoiding any pressure change or strain that could disturb the graft.

Activity restrictions are essential, especially during the first 2 weeks, but should be maintained for 6-8 weeks.

General Guidelines

• Avoid lifting anything heavier than 10–15 pounds.
• Do not bend, strain, or perform vigorous exercise.
• Avoid nose blowing, heavy coughing, or sneezing with your mouth closed.
• Sleep with your head slightly elevated.
• Keep the ear dry.
• Avoid flying until cleared (usually 4 weeks).

These precautions protect the repair and give the inner ear time to rebalance.

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Expected Recovery Timeline

First 48 Hours

You may feel tired, mildly dizzy, or off-balance. Most patients notice reduced pressure symptoms and steadier balance fairly quickly, but hearing changes often take longer. Rest is the priority. Keep movements slow and avoid any strain.

First 7 Days

Dizziness typically improves gradually, though brief unsteadiness is common. Some patients notice subtle improvements in hearing, but it may still fluctuate. Avoid physical exertion, lifting, straining, nose blowing, or sudden head movements.

If there is packing in the canal, it is usually removed at the one-week visit.

First 3 Months

The inner ear continues to stabilize during this period. Hearing often improves slowly, though the degree of recovery varies from person to person. Balance sensations may continue to normalize.

You should still avoid major pressure changes (diving, forceful Valsalva, heavy lifting) for at least 6–8 weeks, depending on the repair.

Most patients return to light work within 1–2 weeks, but high-intensity or physically demanding activities may need a longer break.