The n e w e ng l a n d j o u r na l of m e dic i n e

images in clinical medicine

Perilymph Fistula Test

Hosuk Chu, M.D.

Won-Ho Chung, M.D.
Sungkyunkwan University
Seoul, South Korea

A
42-year-man presented with severe nausea and vertigo, which were precipitated by the ap-
plication of pressure just anterior to the left external auditory canal. Otoscopic examination revealed a choles-
teatoma arising from the pars flaccida of the left tympanic membrane. When pressure was applied to the left
tragus, horizontal nystagmus developed in the patient’s left eye (see video). The development of nystagmus in response
to the application of pressure on the external auditory canal constitutes a positive result for the perilymph fistula test
and suggests the presence of a fistula between the air-filled middle ear and the fluid-filled inner ear. In this case,
left-beating horizontal nystagmus suggested the presence of a bony fistula extending from the middle ear to the left
lateral semicircular canal. Computed tomographic imaging of the temporal bone revealed a lesion with the density of
soft tissue, probably a cholesteatoma, filling the middle ear and mastoid cavity. The osseous portion of the lateral semi-
circular canal was eroded (arrow). During surgical exploration, the membranous portion of the lateral semicircular
canal was found to be intact, and no perilymph leakage was observed. The cholesteatoma was surgically removed,
and the fistula site was repaired. From the time of surgery until his last follow-up visit 18 months later, the patient
reported no dizziness.
Copyright © 2012 Massachusetts Medical Society.

e8 n engl j med 366;4 nejm.org january 26, 2012

The New England Journal of Medicine

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Copyright © 2012 Massachusetts Medical Society. All rights reserved.