Abstract
Objectives: To describe a potentially underappreciated pathology for post-traumatic persistent intractable dizziness and third window syndrome as well as the methods to diagnose and surgically manage this disorder.Study Design: Observational analytic case studies review at a tertiary care medical center.Methods: Patients suffering persistent dizziness following head trauma and demonstrating Tullio phenomena or Hennebert signs are included. All had reportedly normal otic capsules on high resolution temporal bone CT scans (CT). The gray-scale invert function was used to visualize the stapes footplate, which helped determine the diagnosis. Gray-scale inversion can be used to improve visualization of temporal bone anatomy and pathologic changes when diagnoses are in doubt. A search to check for the presence of perilymph leakage was performed in all cases. This was accomplished using intraoperative Valsalva maneuvers. Fat grafting of round and oval windows was performed.Results: Over an 11-year period between January 2009 and December 2019, 28 patients (33 ears) were treated. Follow-up with balance testing and audiograms were performed 6–8 weeks following surgery. Follow-up ranged from 6 months to 7 years. Prior to surgery all patients reported dizziness in response to loud sounds and/or barometric pressure changes. Seven out of 33 ears had demonstrable perilymph leakage into the middle ear; the rest (26 ears) appeared to have membranous or hypermobile stapes footplates. Membranous stapes footplates were better visualized using the invert function on CT. Thirteen patients had a fistula sign positive bilaterally while 15 had unilateral pathology. Twenty-four of the 28 patients (85.7%) showed both subjective and objective improvement following surgery. No patients suffered from a deterioration in hearing.Conclusions: A previously underappreciated membranous or hypermobile stapes footplate can occur following head trauma and can cause intractable dizziness typical of third window syndrome (TWS). Durable long term success can be achieved by utilizing fat graft patching of the round and oval windows. High resolution temporal bone CT scans using the gray-scale inversion (invert) function can assist in preoperative diagnosis.
Highlights
Acute dizziness may be associated with head trauma, which can even be trivial [1, 2]
We have identified a unique cohort of patients who develop immediate or delayed symptoms which overlap quite closely with those suffering from third window syndrome (TWS) of which superior semicircular canal dehiscence syndrome is best characterized [3]
During exploratory surgery we found that presumed leakage of perilymph at the oval or round windows is relatively uncommon; small or large defects covered over by a membrane are often observed in the stapes footplate
Summary
Acute dizziness may be associated with head trauma, which can even be trivial [1, 2]. Persistent, intractable, and sometimes intermittent vertigo or dizziness constitutes a diagnostic and therapeutic challenge. The nature of the injury is often mild and may not result in concussion or loss of consciousness. Many of these patients seek treatment without relief, and when all else fails, they may be inappropriately labeled as suffering from post-concussive syndrome (PCS), or chronic traumatic encephalopathy (CTE). During exploratory surgery we found that presumed leakage of perilymph at the oval or round windows is relatively uncommon; small or large defects covered over by a membrane are often observed in the stapes footplate.
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