The Tullio phenomenon, a well-known vestibular symptoms induced by loud sounds, is usually associated with perilymph fistula and Meniere's disease. It is rarely seen in an otological practice. We report a case of Tullio phenomenon in a 73-year-old male patient with perilymph fistula.
The patient presented to the Department of Otolaryngology, Keio University Hospital with complaints of vertigo and postural imbalance caused by loud sounds. The symptoms were developed 3 weeks earlier and had been especially exacerbated by car horns. The patient had a 2-year history of fluctuations of hearing in the left ear and occasional attacks of vertigo, which typically occurred when belching or inserting a finger in the left external auditory meatus.
Pure tone audiometry revealed a moderate degree of sensorineural hearing loss in the left ear. While examination with Frenzel's glasses showed no spontaneous or positional nystagmus, the application of negative pressure to the left external auditory meatus elicited a horizontal nystagmus beating toward the left.
Further vestibular tests were performed and vertigo and nystagmus were occurred when pure tones (100 dBHL) were applied to the left ear. Exposure to 500Hz tones caused the nystagmus toward the right, and it reversed when 1kHz, 2kHz, and 4kHz tones were applied. When standing, the patient consistently tilted to the left with tones at 1kHz. The fistula sign was again positive, but this time the induced nystagmus toward the right was detected regardless of whether positive or negative pressure was applied on the external meatus. A positive glycerol test indicated the presence of endolymphatic hydrops.
Surgical exploration of the left middle ear revealed intermittent leakage of perilymph from both oval and round windows. The fistulas were closed using fascia and fibrin glue. The patient had no attack of vertigo for 7 months after surgery, and his hearing was also improved.
As a conclusion, we assumed that the inconsistent findings of preoperative nystagmus induced by sound and pressure were due to the intermittent outflow of perilymph from the two fistulas.
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