mvertigo.org · contents abstract ....................................... 5 introduction...

The Perilymph Fistula Syndrome Defined in Mild Head Trauma

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Graphic design by Jerk-Olof Werkmaster Printed in Sweden by Almqvist & Wiksell Tryckeri, Uppsala 1Y8Y

Reprint requests: Dr Robert J . Grimm 2455 N.W. Marshall, Suite 14 PORTLAND Oregon 97210 USA

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Contents

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ABSTRACT 5 INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

MATERIALS AND METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Neurological examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Psychological evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Neuro-otological examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Diagnosis of positional nystagmus . . . . . . . . . . . . . . . . . . . . . . . . . 8 Moving platform posturography . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Perilymph fistula tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Tympanometric fistula test . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Moving platform fistula test . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Classification of minor head injury . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1

Medical management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1 Surgical management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 13 13

Characteristics of PLFS population sample . . . . . . . . . . . . . . . . . . . . . . Prior injuries and the vunerability of women Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Cochlear symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Vestibular symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Stiff neck and headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Perceptal and cognitive difficulties . . . . . . . . . . . . . . . . . . . . . . . . . 16

Patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Revolving doors, escalators, and carrousels . . . . . . . . . . . . . . . . . . . 17 Wading and fishing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Windshield wipers, traffic . and parking . . . . . . . . . . . . . . . . . . . . . 17 Abandonment of reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Memory problems: Yellow stickers and lists . . . . . . . . . . . . . . . . . . . 17 Sequencingdeficits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Reduced ability to function . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Symptom studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Neurological signs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Psychological findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Cognitive disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Affective symptoms in PLFS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Platform vs . tympanometric fistula test . . . . . . . . . . . . . . . . . . . . . . . . 24 Hearing loss in PLFS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Treatment outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Prognostic factors for PLFS treatment outcome . . . . . . . . . . . . . . . . . . . 26

DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 A natural history of PLFS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

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Bedrest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 PLFS from whiplash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Laboratory tests for PLFS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Are PLFS and chronic post-concussion syndrome the same? . . . . . . . . . . . . 31 Perceptual difficulties and cognitive losses . . . . . . . . . . . . . . . . . . . . . . 33

ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

APPENDIX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

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Abstract Neurological and neuro-otological studies were carricd o u t on 102 adults with mild cranio-ccrvical trauma productive o f positional vertigo and perilymph fistula a s confirmed hy lahoratory tests. and hy the finding o f perilymph fistula at tympanotomy in the surgically managed group. In this patient group. all other neurological and neuro-otological diagnoses were excluded, e.g. epilepsy. cerebral palsy, multiple sclerosis. retardation; and for the neuro-otological group those with a history of ototoxicity. lahyrin- thitis. Meniere's disease. chronic car infections. o r developmental or familial disorders. Emphasis in this study was on mild trauma: fewer than half of the sample had been rendered unconscious in the injury o f record, and a third of the cases were of whiplash type. with no loss of consciousness (LOC) and no rememhercd headstrike. These concomitant lesions comprise the perilymph fistula syndrome (PLFS) with a unique profile of neurological. perceptual. and cognitive deficits resembling a post-concussion injury. A complete description o f the clinical picture is given. including psychological. cognitive and diagnostic tests. and thc outcome o f hedrcst vs. surgical management. PLFS can arise from minor t r w m a . fistula arc frcquently hilateral (71/102), a mild sensorineural hearing loss is of variahlc occurrence ( 5 3 % ) . secondary hydrops is not uncommon, and women appear more vulneruhk than men for dcvclop- ing the syndrome. As hased upon comhined lahoratory techniques and clinical symptomology. fistula wcrc correctly predicted in 61 o f 65 laser-operated car\. 'The positional vertigo component o f PLFS was in all cmcs miinaged according to a speciiil physical therapy program utilizing cxcrcises for vcstihular symptom habituation. Even when diagnosed late. a good-to-exccllcnt outcome wa4 achieved in 70% of t re:i t ed pat i c n t s.

Introduction In this clinical paper. we examine the neurology. diagnosis, and treatment o f the perilymph fistula syndrome (PIES) of the inner ear in 102 mild cmnio-cervical trauma patients. only 32 of whom were briefly unconscious. On the basis o f our findings ( N ) such concomitant lesions can be diagnosed by 1;iboratory methods alonc with a n accuracy of 90'56 for fistula and grcatcr than 90% for positional nystngmus; ( h ) that the signs and symptoms of PI.FS cluster uniquely iis ;I syndromc. a n identity all thc more important ;IS i t is treatable; and ( c ) that as PLFS is LI subset o f chronic post-concussion c a ~ e s . i t is important t o straighten o u t thc diagnosis a s

the post-concussion label is often ii dead end with no agreement upon treatment. pathology, or prognosis.

Aftcr exclusion of cases with other ncurological or neuro-otological disorders. all paticnts selected for study had laboratory-confirmed positional vertigo and perilymph fistulas, according to two separate measures; 4l (a total o f 66 fresh ears) of our patients with fistulas so identified eventually wcnt to surgery where such leaks were visualized and videotaped in roughly 90% of cases. The combination of fistula and positional nystagmus was dcscribed in 1976 (Healey et al.. 1976) after i t became known (Fee, 1968) that fistula could result from head trauma as well as from stapes surgery (Staffen et al.. 1963) or chronic ear infections (Harrison et al., 1967; House. 1967). Presumably. headstrikes or angular acceleration forces produce tears in the round window (RW) or oval window (OW) membranes (or both: Fig. 1 a) resulting in a leakage of perilymph into the middle ear space. In the same accident. otoliths are dislodged from the utricular macule (Fig. 2h, c) and accumulate on the cupula of the posterior canal (cupulolithiasis; Schuknecht, 1969. figurc I c). This destroys the zero buoyancy between semi-circular canal cupula and endolymph. causing a position-induced nystagmus usually benign paroxysmal positional nystagmus (BPPN; or benign paroxysmal positional vertigo: BPPV, emphasizing symptom over sign).

If inner ear structures arc not quickly healed, a unique neurological syndrome ensues, as postulated by Gordon (1977) but not described in the otological trauma literature (Toglia & Katinsky, 1976; Wurtele, 1978; Grewel e t al., 1983; Lehrer et al.. 1984; Strohm, 1986). Ataxia, vomiting, tinnitus, and sensorineural hearing loss (SNHL) are markers for acute

1*-898413

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6 R . J . Grimm et al.

A , Posterior Semicircular Duct

mpulla 01 Posterior Semicircular Duct

Right Inner Ear - Superior View (Schematic)

B Normal

Otoliths \

Posterior Semicircular Duct

C Cupulolithiasis

\ Dislodged Otoliths Sink and

Utricle and Adjoining Posterior Semicircular Duct Fig. 1. (a) Schematic otic capsule anatomy with arrows indicating OW and RWfistul;ir. ( h ) ('utaway view o f ihc miicuh of the utricle and otoconia. ( c ) Post-traumatic cupulolithiasis.

PLFS. As SNHL may be mild or absent and symptoms rescmhle those of acute post-concussion, patients are reassured and sent home to bed.

In time, PLFS symptom metamorphosis occurs but with a Faustian twist. After vision i s brought in by the brain to compensate for labyrinthine losses, trouble begins. While disequilibrium, stiff neck, and headache dominate, patients become disoriented in visually complex situations and curious aberrations crop up in short-term memory, concentration, and

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PLFS defined in mild heud truuma 7

reading. Workers lose efficiency, make mistakes, and exhaust themselves trying to keep pace. The brighter accommodate to a lower level of function; the less gifted falter. Fatique, depression and a mild agoraphobia supervene. Symptoms may increase with exercise. conventional physical therapy. and pharmaceutical.

PLFS patients tire of describing their experiences and resent the implication that they malinger or unconsciously promote their troubles. They may remain silent about odd perceptual experiences and cognitive slips. a s such arc not intuitively linked to their accidcnt. or. for fear o f being taken for mental cases. Many worry that they arc developing Alzheimer's disease. For neurologists and a11 others who care for post-concussion o r whiplash patients who decline. our experience will hc helpful. For those who present with a history o f cithcr post-concussion o r after months. an unresolved cervical strain (whiplash). the question: How many have PI.FS'? should he present i n your differential diagnosis.

Materials and Methods I'AIIENTS

From a n ongoing study o f minor head injury, data was rcviewcd on 380 patients collected from Oregon and southwestern Washington statc between 1987 and 1987. PLFS was idcnti- lied in I67 with I02 individuals sclcctcri f o r review: children. patients with pre-existing neurological disorders o r iicuro-otological disorders specifically a history of chronic ear infection>. labyrinthitis. Mcnicrc's syndrome. o r exposure to neuro-ototoxic drugs, a dcvclopmen- tal o r family history of either hearing or balance difficulties. and those with ambiguous or incomplete data were cxcludcd. Thc sample includcs 65 women and 37 men between 18 and 70 years of age: male: .x=40.0: S.I).=11.3; fcmalc .x=37.4: S.D.=IO.I . With a few exceptions. all patients were initially seen by the senior author for symptoms lingering after what had secmcd at thc time t o have been a minor injury.

NIilJROl.O(iICAI, EXAMINATION

t tistory-taking focused o n the accident on record. with attention to hcadstrikes, loss of consciousness (LOC) and its duration. emergency department (ED) visits, hospitalizations. lcngth of stay. and other medical records. In addition to neck. headache, and disequilibrium symptoms. data was sought for cognitive disturbances in work. social and recreational interactions. and in situations where learning and pcrformancc were critical. Responses were sought for symptoms associatcd with perceptually complex situations such as walking in the dark. elevator rides. or experiences in geometrically-patterned spaces. What of short-term memory? Were lists o r stickers used as reminders'! Was there trouble in concentrating? Had reading for pleasure stopped; if so. why'? In work sequences, were thcrc lapses or breaks? Prior trauma. vehicle accidents, exposure to ototoxic substances. substance abuse, and otologic or balance problems were recorded. Family history, occupation, education, prior psychiatric disturbances. and the status of any pending litigation were recorded.

Examination focused on balance. The standard Romberg test (invariably normal) was followed by a modified or the 'sharpened' Romberg (heel-toe) test. Patients assumed a relaxed stance with eyes closed for 30 s and then assumed a heel-toe position. If they did not fall, a tandem walk was attempted. Patients were checked for hearing, cerebellar signs, neuro- pathy, and for reflex accentuation or asymmetries, cranial nerve disorders other than VIII. extraocular muscle (EOM) abnormalities. and positional nystagmus. Drum-elicited op- ticokinetic (OKN) responses were recorded such as aversive head turns or body tilts, eye closure. swallowing, or neck stiffening. Patients read while eye movements were studied with a

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8

hand lens. Electroencephalography (EEG). computerized tomography (CT: for temporal bone window inspection), and magnetic resonance imaging (MRI) were obtained as needed. Data was stored in an electronic database (dBase I l l + ; Ashton-Tatc, Boston, Massachusetts) using an IBM PC with 20 megabytes of memory. Analysis was performed on 273 data fields, using statistical (Statpak, NW Analytical Inc. Portland, Oregon) and graphical software (Geography; Geocomp Inc. Concord, Massachusetts).

R. J . Grimm et al.

PSYCHOLOGICAL EVALUATION

Thirty-eight PLFS patients were referred for outpatient psychological studies, 21 female and 17 male; average age = 35.9 years based on (1) the clarity of thcir recognition or concern for difficulties in thinking, and (2) not being averse to have these matters investigated. Consulta- tion was secured with a medical psychologist (P. R. L.) with 12 years' cxperience of thc neurologically impaired. Examination includcd a bricf mental status evaluation with review of subjective complaints and the administration. scoring. and interpretation o f selected psychological tests including: Wechsler Adult Intelligence Scale-Revised (Wnis-R); Rey Auditory Verbal Learning Test (AVLT); Trailmaking Test (IT); Wechsler Memory Scale (WMS); Symptom Checklist-Revised (SCL-90-R); Minnesota Multiphasic Personality In- ventory (MMPI; minimult version) and the Rey-Ostcrrieth Complex Figure Test.

NEURO-OTOLOGICAL EXAMINATION

General

Neuro-otological examination consisted of a thorough ENT history and rcvicw of symptoms. appraisal of oculomotor movements (EOMs). gaze fixation suppression. and axial stability. Tympanic membranes were inspected with a microscope using pncumotoscopy. Laboratory tests included: pure-tone audiomctry. specch discrimination. tympanometry. acoustic reflex measuremcnts, and both the tympanometric (Hennebert) and the platform fistula tests (Black et al., 1987). Electrocochleography (Ecog; for the study of endolymphatic hydrops), auditory brainstem evoked responses (ABERs). and multiple frequency tympanometry (Lilly, 1984) were used as indicated. Vestibular function was evaluated by electronystagmo- graphy (ENG), Cawthorne-Hallpike mancuvers. positional, and caloric tests and also by rotational tests (visual-ocular reflex; VOR) and by moving platform posturography (Black, 1985).

Diagnosis of positional nyslagrnus

Positional nystagmus was confirmed in all patients by two methods. The first test utilized the Cawthorne-Hallpike maneuver conforming to the definition set by Baloh et al. (lY7Y). In this test, a burst of nystagmus is sought 6-10 s after a patient is rapidly moved from a sitting to a head hanging position. Cupulolithiasis of the posterior canal generates a torsional nystagmus with the fast phase upward toward the forehead; it may reverse itself when thc patient is righted. In BPPN, such phenomena habituate with serial trials. Vertigo may only occur with the initial maneuver or persist with cach subscquent maneuver.

Moving platform posturography

A more sophisticated method for assessing positional and postural disturbances (from distorted canal function) is the use of a controlled platform and visual surround for systematic testing of sensory feedback for control of posture (Black & Nashner. 1983; 1984a; Black,

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PLFS defined in miid heud traumu 9

4 -- Platlorm m s in

proportion to patient's center4

gravity (I e support surlace

provides rm spatial

orientatm response

1 1

/.Y,q. 2. Schemutic.; f o r thc controllcd platform in the .;tudv of vcstihulospiniil posture control a n d fistula dctec- tion

19x5) a s portriiyed in Fig. 7 . Alrwmc ( a h did Romberg) that three sensory systems arc inte- grated i n standing, viz. labyrinth, eye. and proprioccptivc wnsors. For analysis. the idea is t o isolate the work o f cach hystcm. A platform which can be servo-controlled for visual and proprioceptive feedback by body sway makes this possible (Nashncr. 1071; 1976). If the platform is servo-coupled to body sway there is essentially no change in the angle of the ankle joint referenced to the platform. thus removing ankle prsprioception as an effective orientation reference. I f eyes are closed or the visual surround and platform are coupled t o body sway, the vestibular system is rclativcly isolated from visual and proprioceptivc cues for the control of upright stance.

In patient5 with vestibular distortion. vision i> deployed for balance (Black & Nashner, 19x4 h ) . PLFS patients give a mixed pattern o f postural dyscontrol. combining the difficulties associated with remaining upright when given erroneous visual information (about A-P sway) with those o f vestibular-deficient patients who fall when relying on vestibular informa- t ion alone (Black & Nashner. 1 Y x 4 ~ . b ) .

f'erilymph fisridu tests

The laboratory diagnosis of perilymph fistula rests on the application of pressure to the external ear canal and searching for a measurable change in vestibular output. Under normal conditions, n o responsc-subjective or objective-should result when positive or negative pressure changes (from ambient) are presented t o the external auditory canal. Two tests were used on each patient: the older tympanometric (Hennebert) test and the newer moving platform fistula test (Black et al., 1987). All patients had positive fistula tests by one or both methods.

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10 R. J . Grimm ef al.

NO FIS1'ClI.A

<:

SERVO G A I N 0.0

0 ;P

0

1 0 . 2 5

0 P !

i

F I S'I'U L A

1 . &&&&&&& (:

i r

P

P Fig. 3. Platform Fistula Test. Traced rccords from 10 patients without fistula in tested ear (leff column) compared with 10 patients with fistula (right column). Balance is first tested without prcssurc applied to the ear canal (Control). Pressure 15

then applied with the platform stahle and repeated as sway-induced feed- hack ( 2 5 % and 50'%,) i \ removcd. increasing test scnsitivity l i m e and amplitude marks are givcn.

Tympanornefric fisfuku test. The tympanometric fistula test is a standard test utilizing thc vestibulo-ocular reflex (VOR) as its response. Positive and negative watcr pressures (SOU mm) are alternately applied to thc ear canal via B tympanomctric probc. Modulated canal pressurcs should not stimulate thc normal vcstibular system. Evoked nystagmus with an in - tact tympanic membrane (Hennebert's sign; Hennebert. 1905). nausea. vertigo and body tilt are scored 'positive', 'questionably positive' (vertigo. spatial disorientation. or 'negative' (no response) for each ear. Where exact control of canal prcssures have bccn used with ENG-recorded rcsponses. fistula prediction is correct only 56% of the time (Supence & Bluestone. 1YS3) similar to our findings with this mcthod (Results). Less rigor gives poorer rcsults, e.g. 26Y0 fistula confirmation (Singleton et a l . , 1978). As will be shown (Results), whcn the tympanometric fistula test was positive. its accuracy rivalled that o f the platform fistula tcst . Thc problem however lies with its sensitivity: whcn the tympanometric fistula tcst was ncgiitive, it missed roughly half the fistulas identified at tympanotomy. a finding in accordance with thc observation of others.

Moving platform fisfuula rest. The controlled platform can also be used for detecting perilymph fistula (Black et al., 1987). Defective postural responscs were sought in subjects required to control upright stance while external ear canal pressures were modulated with 1 Hz sinusoidal pressures applied to a canal. Such stimuli give no auditory or vestibular response. In the fistula patient, changes in the ambient pressure induce a measurable sway parri passu with the stimulus, as shown in Fig. 3. When stimulus-induced sway amplitudcs were greater than 50% of controls, the test was recorded as positive. Patients who fell with application of external canal pressure (test incompletion) were marked 'questionable'.

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PLFS defined in mild heud t r u ~ m u 1 1

N

t 1 2 3 4 5 6 7 8

I Female Male

1 2 3 4 5 6 7 8

Loso of C o n s c l o u n c s s N o No No No Yes' Yes' Yes' Yes'

Head Strike N o No Yes Yes Yes Yes Yes Yes

Previous Head Injury No Yes No Yes No Yes No Yes

'LOC < 120 sec. 'LOC ' 120 s e c . F/,q J Frcqucncv o f cI;isscs in PLFS

('I,ASSIFI(~I\TION Of' M I N O R t1EAD IKILIKY

A cl;issific;itiori schcinc sensitive to mild injuries ;ind population dis t r iht ion is shown in Fig. 4. O u r popiil;ition W;I\ divided into eight cl;rsses h i i d on ( 1 1 ) whether or n o t there had been ;I hc;idhtrikc (othcr than headrest). ( I ) ) lash of consciousncs5 (l,O<'), and if LOC. a duration oE ( t . ) Ic\\ or ( t l ) greater th i in 2 inin: a n d ( c ) . ;I prior treated hc ;d or neck injury ;it the level ot ;I ht i ir i o r lr;ink LO<'. 'I'hcrc ;ire no uniformly accepted definitions o f "mild" head injury (Hinder. I O X h ) . I t ha\ uwi i l l y incant either ;I short period o f unconsciousness (less than a n hour) or if con\cioiisncss hiis hccn preserved. ;I transient ;ilteration of neurological function (Cicnn;ii-clli c t i l l . . 1082; Binder SC RaJdock. IOXO). All o f our patients wcre g r x k 15 o n the Glirsgow ('oma Scale at the time of ED review and all f i t ;I "mild" t o cxtrcmcly mild category in the 1itcr;iture. ( ' lass I paticnts had n o heiidstrikcs. LOC'. prior injuries. and (usually) n o ED visit. Cl;iss I patients wcre o f cxtraordiniiry intcrcst ;IS thcy were t o demonstrate PLFS without loss of consciousness and without ;I rcmcmhered headstrike. Class X was represented by ;I single patient with u headstrike. LO<' beyond 120 s. and two prior head injuries. He was alcrt and sensate in the ED IS min Iiitcr. Our PLFS population mainly consisted o f patients hclow Class 5. viz. those without LOC.

'TREATMENT

Madicul munirgrment

In the absencc o f precipitate SNHL, all patients regardless of illness duration were initially treated o n a &week progr;im o f strict bcdrest in which most of the day was spent reclining in bed or o n ii couch with the head propped to 30". The rationale was t o control fluctuations

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in pressure across fistula in order to permit strengthening of Type 2 collagen cross-linkages, a process taking roughly 6 weeks. Bathroom. shower, and sitting for meals is permitted. As- sistance was children, shopping, cooking, and household chores were managed by others. Prohibitions included: no lifting, cooking, shopping, sex, roughhousing. travel, carrying, walking stairs, and no elective surgery of dental work. Other measures included stool soften- ers, a non-constipating diet, cough suppressants. antihistamines to prevent sneezes with al- lergies, control of hypertension. and stress reduction. Physical therapy exercises performed in bed were encouraged for older patients.

Re-evaluation including audiometry is given at 6 weeks. Fistula re-testing is omitted for 6 months and preferably 1 year to avoid reopening fistulas that have closed. If fistula symptoms persisted, the bedrest treatment program was considered a failurc. The patient has a choice of another 6 weeks of bedrest o r surgery; most choose surgery.

For patients whose fistula close with bedrest. activities were incrementally increased for one month and then vestibular physical therapy (Table I ) was begun for training in postural strategies (modifications of Cawthorne. 1946; Cooksey. 1046; and Brandt & Daroff. 1080) t o habituate position induced symptoms. The goal was a twice daily program (one year) of sclf- administered vestibular and postural exercises, 15-20 min per session. Each cxercisc was repeated 3-5 times with a progressivc build-up to morc difficult maneuvers. Flying. scuba diving, elevation changes, or strenuous activities such as heavy lifting were prohibited for a year.

Surgical management ( E 0. Black) If bedrest failed or a patient's condition deteriorated. a standard exploratory tympanotomy was performed under microscopy and all fistula videotaped. Both oval and round windows were repaired with tissue grafts. The Argon laser was uhed to remove any abnormal fibrous bands and to denude mucosa around the windows t o prepare the graft site. Subcutaneous post-auricular areolar tissue (Seltzer & McCabe, 1Y86) was diced and then dipped in a biological glue of fresh. cryo-precipitated autologous fibrinogen and commercial bovine thrombin and packed onto the lasered site. Patients remained at bedrest for 6 weeks and follow the bedrest protocol. Operations for repair of bilateral fistulas were staged to take pliicc 3 or more months apart. Repeat fistula testing was delayed for at least 6 months after surgical closure.

Table I . Vestibular therapy for positional nystagmus

Seated: Track and focus printed targets at arm's length Head tilts. slow to rapid Head rotations, slow to rapid Weight shifts, left and right with head ercct Fallovers to pillow; remain down 10 s: return to vertical (Hallpikc) Standing (eyes open, closed) Feet together; focus balance 30" Weight shifts: Feet together, feet apart. torso rotated, arms extended Heel-toe stance Single leg balance Walking (eyes open, closed) Rapid turns, building up to 180" Head fixed right, left; add turns Heel-toe

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PLFS dejlfined in mild heud trtiirma I3

Resu 1 t s Cl1ARACTERISTICS OF PLFS POPULATION SAMPLE

All I02 patients had the laboratory criteria f o r PLFS: further definition o f the symptoms and \igns for this syndrome will be provided shortly. Addition;il information about this population is shown in Table 11. With ;I few exceptions. we report on chronic PLFS cases. most o f whom had been injured months o r years before. A significant varimcc was recorded for the intcrviil between injury and diagnosis, even after the simple size was paired to exclude acute cases and those with injuries beyond 4 years o f diagnosis. All patients had traumatic injuries. 7X from automobile accidents (68 plus I0 vehicle xcictcnts whilc iit work). 70 with headstrikes. c.g, against windscreen glass, dashbo;irtf, 31 of whom sustained concussion. O f 32 with o n l y ;I recorded neck injury. women wcrc disproportion~itely represented (23l.72). suggesting ;I vulnerability to PI.FS from this route. PLFS paticnts who showed up in the ED after :in accident wcrc either those with concussion ( l l M ) ' % , ) o r after ;I hcadstrikc (51.3'%,): ii

whiplash alone seldom brought any of this population t o the EL).

I'KIOK IN.ICJKIES A N D T H E VCJ1,NEKARILITY 0 1 : WOMEN

Do prior injuries makc one more vulnerable to PLFS? Are thcrc differences hetwccn thc scucs? 'l-hc ;inswcr t o both questions mav tic 'yes'. Vrilnerahilitv of women for PI.FS is suggested in T;ihlc Ill. Of ii total 7(1 hcadstrikc piiticnts. 43 wcrc wonicii. XI '%, of whom ;ilso h;id neck in,jurics. This hcadstrikc-neck injury cornhiniition ;iccountcd for the majority of tcm:ilc F.1) visits and : i h o u t half o f the concussions. Of I X women with concussion. 13 had ;I

prior neck injury Further, the largest subset o f hospitalized P I I S patients wcrc women with combined hcadstrikc. neck injury. ;ind LOC.

Prior injuries incrc;iscd the likelihood of fistula surgery. In Table I l l . 43 o f 65 of PLFS women (07 'L ) reported prior hc;id o r neck injuries (usu;illy from vehicle collisions). Of these women, 20 o f 29 ( h X " 4 , ) went to surgery. v \ . 3 of 15 men ( 2 0 % ) with ;I similar history o f prior

t1

Age iit injury I>i;ignostic (week\ po\t injury) Vchiclc accidcnt loh injury Other injury Neck injury Hcadstrikclno LO(' Concussion

i l 2 0 s 3 1 2 l l h

Emergency room Neck injury Headstrikdno LOC Concussion

Neck injury Headstrikdno LOC Concussion

Hospital

It12 35 .32 I 0 . X 75.x2x4 5 (1X

27 7

32 3 0

25 h

J X

20 31 17

7 &

37 40.0? I I 3 70 8281.7 1') Ih

9 1-1

7 -

I 0 3

Ih

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14 R. J . Grimm ei al.

injury. For men, a prior history of injury appears not to prejudice the case for improvement on bedrest alone; their chances seem better than women. For the bedrest group, prior injuries were also common, recorded by roughly two-thrids of women and a slightly greater proportion (72%) for men. For the entire PLFS population, more than half (58.8'26) had a prior, treated head or neck injury.

Finally, there was also a difference between sexes with respect to PLFS and those with neck injuries alone (mostly whiplash). Table I1 reveals that 23 of 65 women (35%) developed PLFS in association with neck injuries alone, vs. only 9 of 37 men (2S"/,) . This difference is magnified by the fact that 87% of neck injury PLFS in women came from vchiclc collisions. vs. only 28% in men. For thin-necked women involved in automobile collisions, the risk of developing PLFS is as great for whiplash alone as it was from a headstrike with LOC.

SYMPTOMS

PLFS symptoms arise from three sources: cochlea. vestibular labyrinth. and from brain in rc- sponse to erroneous sensory information. The role of Type 1 articular mechanoreceptors from high cervical vertebrate (Wyke, 1967: Molina et al.. 1976) in neck-injurcd PLFS patients is not known, either with respect to time. labyrinth damage. or on the low-gain. cervical-ocular reflex (Barlow & Freedman. 1980) in humans. Fig. 5. summarizes the frequency of occurrence of common symptoms in chronic PLFS.

Cochlear symptoms Tinnitus, fullness in the ear, and fluctuating hearing loss occurred with fistula of cithcr the RW, OW, or both and could also be associated with a secondary degenerative endolymphatic hydrops. Similar to the observation o f others (Strohm. IY86). no correlation could be madc between symptoms and fistula site. e.g. OW. RW or both windows. Patients complained o f tinnitus and sometimes of leaking or 'popping' sensation. As Kohut ct al. (1979) and others. e.g. Singleton (1984) have noted, surgically verified fistulas are frcqucntly found in the absence of SNHL. A hearing loss >20 d B was prcscnt in 53% o f our PLFS cases. I f hearing loss is present, i t may be conductivc and not SNHL. Conductivc losses arise from ossicular chain

Table 111. Prior injury and trmtrnent groups

Female. Fcnialc. Male. Male, hedrest wrgery hcdre\t wrgcry (n=36) (n=29) ( n = 2 2 ) (n=15)

Age Diagnostic week History:

Prior vehicle accident Prior neck injury' Prior head injury' Prior concussion

Accident of record: Vehicle accident Job injury Other injury Neck injury Headstrikeho LOC Concussion

* Distinct groups

36.0 72.6

31.2 86.4

3X.V 60.3

36.1 86. I

13 X

I2 3

30 S 1

14 14

R

I 2 7

I 2 I

7 X

4 5 6

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PLFS dyfined in mild heud rruumu 15

Total Population, n = 102

DYsrgulLraRNar

HEADACHE

MEMORY Loss

TINNITUS

NAUSEA

CONFUSION

VERTIGO

CLUMSINESS

Visu,u PERCEFTION

STIFF NECK

HEMZING Loss

EAR PNN

0 10 20 30 40 50 60 70 HO 90 100

Pcrccntage with Sviriptom

derangement or footplate fractures. PLFS patients often reported abrupt. transient hearing changes: ..I t ' \ ;I> i f one o f my stereo amplifiers was turned o f f . " Such events may l a s t scconds. niinutcs. o r ;I few hours. There in;iy he l i t t l c or no hearing loss. while fullnc$ and tinnitus in- crciisc. I h c p car pain c m iiiclic;itc ; i n occult ot ic capwl:ir fr;icturc. disruption of thc ossicular c+i;iiii. o r he related to ii t c m ~ ~ o r ; i l - n i a r i ~ l i l ~ ~ i l ~ i r joint injury.

Vc \ [ i t ) id lo r sj' t r i p l o n IJ

L)iscquilihrium. dizziness. ;I sense o f spatial disorganization. vertigo with physical activity. "fuuincs> o f thinking". and a chronic. low-grade naiiscii were common. Syniptoms were triggered o r aggrav;ited by changes in external pressures on t h e inner c;ir. e . g elevators. mountain travci. air flights. sneezing. diving. or weather changes.

.SIi/J I 1 rdi 1111 cl / I ( , ( I tlut . I f c PLFS patients have nagging stift' necks a n d muscle contraction tvpc o f headache. occasion- a l l y with ;I vascular component. I f unilateral. patients wt'rc reviewed for ;I temporo-mandibular joint injury. ('upulolithiasis, c.g, BPPN. i n u y he responsible for a characteristic morning headache. Presumably. patients lie through the night in the plane o f the damaged canal. in- ducing enough co-contraction o f labyrinth-influenced neck muscle t o give morning discomfort. The fistula may he responsible for headache worsening through an active day or with physical exercise or iierobic routines. Such altered algorithms extendcd soreness and stiffness t o axial musculature. Co-morbid conditions must he factored. e.g. temporal mandibular j o i n t injury, cervical spondylosis. prior back injuries. etc.

For the neck. there may persist a ratchcty motion in horizontal traverses a s i f neck turning had lost an integrating step. In the acute period. when asked t o hold thcir head steady and make 45" voluntary saccades to an object of regard. patients reported ii transient twinge o f neck pain ipsilateral to the direction o f gaze. As simultaneous commands are sent t o oculomotor and neck muscle motor neurons. this pain must arise from injured conncctivc tissue tugged by contracting muscle. When the head was steadied by thc examiner. and the patient

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16

swivelled back and forth on a stool (cervico-ocular reflex maneuver), neck discomfort without vertigo was described. even in patients with acute injuries.

R. J . Grimm et 01.

Perceptual and cognitive dificulties Table IV introduces two fascinating aspects of PLFS. The first is increased disorientation, nausea, and disequilibrium in perceptually complex situation 'busy' to the eye such as geometrically-patterned environments, situations with wide-field motion, e . g . crowds. o r where the eye and inner ear were at odds. e.g. escalator rides. Such expcriences promoted a rctrcitt from public life and gave the appearance of a mild. acquired agoraphobia.

The second observation is that it is true. PLFS patients 'don't think straight'; all those studied revealed defects in first ordcr cognition by ncuropsychological testing. Table IV also provides a partial listing of intellectual chores that falter. Seldom linked by PLFS patients t o the recorded accident, these unexplained difficulties were at the root of fear (unfounded) for Alzheimer's disease. We have lumped these two symptom complexes together as 'perceptual difficulties'. They were more easily rccognizcd in the chronic. stabilized deficiency period o f PLFS when balance depends upon vision.

Symptom profiles for perceptual difficultics were unique for each patient. a function o f i i n

individual's experiences, temperament, age. education. work. and social life. A search wab made to uncover odd perccptual cxpericnces in familiar circumstmces. e.g. as in going down a stairway. or for difficulties with sequential processes such BS running columns of figures o r scrolling a computer screen during word processing. Two PI.FS patients who wrotc trntlc newsletters on word processors found it took days t o accomplish what had formcrlv becn done in hours before their injuries. Whilc such perceptual difficulties arc' not unique to

Table IV. Perceptual and cognitive difficulties in chronic I'LES

I . Aggravating environments I'uttrrn.c Supermarket aisleways Stripes. dots and checks Stairways Printed text Multiple voices

Referential mmwnenr Elevators Escalators Revolving doors Airport luggage helts Moving water Hcavy traffic Windshield wipers Crowds

I I . Cognitive disorganization Functional losses Simultaneous activities Short-term memory Mental focus Performance of sequences Concentration New learning Reading Energy

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PLFS d e f i n e d in m i l d heod troirmu 17

PLFS, they are strikingly clustered here. Additional details are provided to give a flavor for such inquiry.

PutIcrtis. Supermarket aisleways (with patterned, vanishing point perspectives) stairways. and terrazzo floors, were symptom-enhancing environments as provoking as ironing polka- dotted clothing. I n supermarket aisleways. patients watched the floor. shopping cart. o r fixed their gaze ahcad on scmc stable target. Visits were confined t o mornings or late evening when fewer people arc about. PLFS patients gave up social gatherings t o avoid an increase in symptoms from the confusion o f multiple-positioned voices and people movement. Shop- ping malls were shunned f o r siniilar reasons. Portland International's airport lobby has a patterned carpet which stretches endlessly. The astute reported difficultics in just being there.

H c ~ \ d \ ~ i n g dfior.s. ~.sc~uliitor.s, untl c~arrou.sc4.s. PLFS patients arc thrown o f f balance by l o o k - ing ;it o r just thinking ahout ;I revolving door. Entrance and exit hesitancies evoked mu1 t / ' t , , , r /~ i i , c / i rc , , r lc . r l r . i .c. the persistence o f sway illusion after ;I ridc o n II small boat. elevator. cxxlator. ctc. Where possible. PLFS patients t o o k stairways with handrails. Carrousel star- tups in airport baggage ;irc;is reminded patients o f wathing waves a t the beach.

Wirtlirrg tirrtl j ; . sh ing . PI.FS patient attempts t o w;idc in shoreline water provoked unser- t ; i i n t y : sometimes even t'iills. Boat trips and fly fishing were given up because moving water induced ;I continuid sense o f unsteadiness: unstable horizons defeat the compensating eye. T V niovic chase sccncs from San Francisco hills exacerbated symptoms. The 'waterfall' cf- icct . v i i . thc illusion created by staring fixedly at it waterfall for ii minute. and then making ;I giuc shitt t o an adjacent wAl (the waterfall frame moves upward) was disorienting. somc- t i m e \ prccipi(ating ;I fall when first encountered after ;I head injury.

Wintl.diwld n8ipt'r.s. truJ;c,. und ~ i o r k i n g . PLFS patients found i t difficult to drive in the rain a n d especially when i t was snowing. the latter coupling wiper motion with both a turbulent vi.;ual foreground and pcriphcry. Misjudgnicnt of distances and speed. taking curves too widely. and panicky feelings from oncoming traffic were reported. Scraping the sidewalls o f tires against ;I curb during ;I wide turn wi15 common: parking using a side view mirror was tin ;rilvcnturc. ,411 cxprcicnccd truck drivcr with ;I ten year history o f perfect driving. tore off a side view mirror in ;I routine hackup of his semi-trailcr truck trailer into ;I loading dock. On the same day hc misjudged ;I t u r n at ;i corner. damaging a parked car. the first accident(s) o f hi\ cxccr . When possihle. PI.FS patients restricted driving to light traffic and in daylight. One woman got lost on l'ortland's frccways because >he couldn't read signs while the car was i n motion (owillopsiii). She thought she w;is going m;id, ;IS she was in familiar territory and had driven the route numerous times.

Ahtrritlonmc,nr o / r i d i n g . Most PLFS patients gave up unnecessary reding a s print appeared blurred or words scemcd t o .fl i t around'. Routine eye checks proved negative. A change o f glasses was pursued without hcnefit. Combined with the need t o re-read para- graphs several times to get the meaning, frustration led to the abandonment of rcading for pleasure. Student grades suffered. When eye movements o f a PLFS patient with such complaints were checked with a hand lens during reading. saccades appeared jittery. When the eye reached the end of ;I line. the return saccade was marked by overshoots and often required several tries to capture the target word. I t was the loss o f the facile ability to place the eyc t o the next line which scemcd off. as i f 'rastering' had been lost. A raster device provides a DC step at the end of a cathode ray oscilloscope (CRO) sweep to reset the next sweep below its predecessor similar to a typewriter. In PLFS, loss of 'rastering' may underlie the 'blurriness' complaint. reprcsenting a lowering of visual threshold during saccades to produce an image slip rather normal blanking o f perception. another cause o f blurring was the inahility to suppress nystagmus.

Memory p r o b l e m s : f i l low stickers und lists. PLFS patients were embarrassed by short- term memory losses. The 'yellow sticker sign' was common: patients resorted to writing notes

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18 R . J . Grimm e t al.

Fig. 6. Photograph of rr paticnt's work station with a cluster of reminders pasted 10 the hoard .

on yellow paper squares with adhesive hacks for placement in some usual haunt. e.g. rc- frigerators. as reminders of appointments, phone calls. and shopping duties. Fig. h is a photograph o f just such a cluster o f rcminders above a work station. Forgetting the mission when walking from one room t o another, or one of two items on ;I shopping trip was cxtrcmcly common. One paticnt broke down when she described walking into thc family bathroom and could not remember which toothbrush was hers. Storing new information was unreliable and learning anything complicated was anxiety-provoking. Such observations arc emhroider- cd in all PLFS histories. I t cannot be said too strongly how threatening this is to ii patients. spouses, friends. and employers. An "1 can't think straight" statement from a PLFS patient must be taken seriously.

Seyuenring deficits. PLFS patients stumbled with the performance of almost any kind of learned sequence. The perceptive recognized such lapses as peculiar, untimely, and unprc- dictable: a PLFS bartender forgot mixing sequences; musicians recognized dropped notes after the fact: an accountant lost track in entering figures ("its as if the whccls stopped"); a wood craftsman (Case No. 9) forget tool use sequences, etc.

Reduced ability to function. One of the odd findings in our PLFS patient sample was that with a few exceptions, none of our patients were working at the time of entry into our program. Those still working held positions permitting coasting or engendered rote duties in sedentary situations. Few PLFS patients can safely and none should work at labor. at heights, or operate machinery.

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PLFS defined in mild head trauma 19

DYSEQURIBIUUM

HEADACHE

MEMORY Loss

TINNITUS

NAUSEA

CONFUSION

VERTIGO

CLUMSWS

VISUAL PERCEPTION

STIFF NECK

HEARING Loss

EAR PAIN Fig. 7. Chronic symptoms: Sex differences in PLFS.

0 10 20 30 40 50 60 70 80 YO 100

Percentage with Symptom

Female

Male

A reduced ability t o function is the sine yicu nun of PLFS. Patients don't appear i l l unless the examiner recognized the subtle signs of motion sickness, viz. limited head, eye. and body movcmcnth. t'requent swallowing (salivation) and difficulty concentrating on the examiner's questions. Ordinary findings don't match the diverse. persistent. and neurotic-sounding complaints cniphasizcd by a drawn out course from what sccmed to havc been a minor accident. Patients cited fatigue, headache. and nausea as reasons. Karcly do they say "I can't function."'l'hcrc is a scnsc of slowing down. an "I just can't do the work", i.c. a loss of crispness and mental facility rcquisitc to work performance work. a reality concealed by embarrass- ment not easily described. I t is defeat by ;I consortium o f symptoms none or few o f which alone would deliver such an outcome. Many concealed their difficulties. hanging on at work a s long :IS possible until they slowly but inevitably "burned out'. Depression was one con- sequence; mitrital stress could he devastating. Divorce and suicidal ideation wcrc not uncommon; we havc had one suicide.

Symptom sticdies

Do PLFS symptoms differ between the sexes'? Fig. 7 illustrates that some symptoms occur more frequently in women, e.g. SNHL. perceptual difficulties. stiff neck, and headache. The latter two symptoms may reflect a relatively greater proportion of women with whiplash.

Does concussion make a difference with rcspect t o symptoms'? Fig. 8 compares symptoms as a function of head injury class, showing that there was little difference between subsets, with the exception of nausea and vertigo. Those with LOC (Class >5) from the recorded accident were slightly sicker. more likely to have SNHL and also had a history of prior cranio- cervical trauma. This is an important point with respect to the differential diagnosis with the post-concussion syndrome: as symptoms are similar. with o r without LOC. the LOC cannot be a crucial variable for either inner ear injuries, or more importantly. as the genesis per se of the cognitive and perceptual symptoms that emerge. That those with whiplash injuries can also present with PLFS is also important for another reason: invariably, such patients were

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DTs~varSRNu

HEADACHE

&MORT Loas

TI"S

NAUSEA

CONNlION

VcRnoo

CLVUS-

VISUAL RRCEFTION

8- NECK

H c " c Loss

EAR P m 1 F ~ K . 8. Chronic symptoms in PLFS by injury class.

o 10 20 30 40 so 60 70 80 90 ion Percentage with Symptom

No Headstrike Headstrike No LOC Concussion

Ei s often those believed to be either malingerers. hysterics. or to have features of compensation neurosis in the unconscious service of unsettled litigation.

Do symptom profiles give clues as t o who will require surgery'? Fig. Y compares symptom profiles between bedrest and surgical treatment groups. PLFS patients who got hcttcr on

DYSEQI~IBRILM

HEADACHE

MEMORY Loss

TINNITUS

NAUSCA

CONTUSION

CLuMSrmSsS

VISUAL PCRCCFTION

STIFF NECK

H W R m G Loss Fig. Y. Chronic symptoms in

I PLFS hy treatment group.

i!l I0 20 30 40 50 60 70 80 90 100

Percentage with Symptom

Bedreet surgery rn

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PLFS defined in mild heud truuma 2 I

bedrest were more symptomatic for X of 12 prime symptoms. One possibility: they may have Ixcn more compliant with the program ;is their symptoms were worse.

NElJKOLO(i1CAL SIGNS

liihlc five lists normal findings m d abnormal signs in chronic PLf-S. Patients often had a col- lection of bruises of varying ages on their shins: they reported clumsincsb in their own home. humping into doorways. coffcc t;ihlcs. table edges which wcrc in plain sight as if familiar ob- .jccts in ;I fnriiiliiir path wcrc not iiccuratcly computed for woidiincc. Their disequilibrium W;IS of ;I vestibular nature. O n the turn into the cxarnining room. they would touch the door I'ranic (VI p i ~ , s , v r ~ n ~ lor it proprioccptive f ix o f the vertical. There wits n o suggc3tion o f a cerebellar walk where nictrics arid structure must be replotted for each step (Nashner & Grimm. 107H). the w;iddlc uf proxiinid wcakncss. o r ii gait of antulgic origin. While thcrc niay he sub- tlc axial instabilities in unsupported sitting. tituhation w a ~ rare. I f present. i t was usually associated with ;I low-amplitude. mild head tremor. Stretch reflexes at the knec were com- monly brisk. presumably trom disinhibition o f vcstihulospinal contributions to the modula- t ion o f spinal cord stretch rcllcxes a n d c~)-contractioii.

G;tzc ;init positional nvstagnius niay tic present x u t e l y hut is usually clinic;illy inapparent iri chronic PI .FS ( i t miiv be mc;isur;ihlc in the 1iibor;itory) a s patients mustered compensatory rcwrvc. Examination o f s;icc;idcs during reading m a y rcve;il the .raster' defect previously de- scritxd. Motion sickness and symptoms of spatial disorientation in PLFS patients were im- mcdiatcly provokcd by O K N testing. 'Thev protested. sw;illowed. closed their eyes. turned ;iw;:y, o r i f they torced thcniwlvcs to track. stiffened and pave smiill aniplitudc. entrained hcad nods. Sxcadc\ evoked by it rotating hand-hcld \triped drum could he reduced in ;implitude. frequency. and could be of irregular length.

I f ;irked to tiindcni walk. patient\ made ;i quick inyxcting swccp of the examining room followed tiy ;I second pausc-gl;incc ; i t the floor route before them. There followed ii cautious if n o t irrcgul;tr tandem walk under direct vision: ;i modified Roniherg (heel-toe) stance ac- complished by axial stiffening hut n o fiills. except. where asymmetrical influences from the labyrinth arc strong. 'The comment ..It's more difficult than I cxpcctcd" was frequently heard. Even i f cold sober. ;I I'L.FS paticnt would have predictable trouble with a roadside drunk test. cspccidly a t night.

When asked t o stand for thirty seconds with fcct apart and eves closed and then to repeat either of thcsc two tasks. PI.FS paticnts appeared 'glued to the floor' for a few seconds bc- fore falling sidewiiys to their surprise iind sometimes tear\. Thirty seconds of eyc closure suf-

Orient ;it ion

Vision Pupillary reflexes Oculoceph;ilic reflex Ocular movements Cutaneous reflcxcs Praxis Associative movements Romberg test-Eyes closed Tandem walk-Eyes open

Speech Speech error < I O'%, Position;il nystagmus < 102, fIead instnbility < 10% Cerehellar < l o ' % Hearing loss <SO'%, Weber test <SO'%, Brisk knec jerk >50':: 0. K . N . >75'%> Neck mobility >lS'% 'Tandcm Komberg-Eyes closed >YO'%, Tandem walk-Eyes closed >OO'%,

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ficed to remove visual memory for support surfaces and unmask the vestibular deficit. Rarely. a PLFS patient performed these tasks with eyes closed, perhaps due to a longer hold of visual memory or effectiveness of stabilizing muscular co-contractions in a fi t patient.

Hearing losses were found in roughly half of PLFS patients and could be either conductive or sensorineural. Finger pulses to the ear canal may induce nausea or deep ear pain ipsilat- era1 to active fistula.

PSYCHOLOGICAL FINDINGS

Cognitive disorder A fascinating finding in PLFS was a decreasc in first-order cognition. When explorcd. not a single patient in our series escaped from such handicapping experiences. To further study cognitive difficulties associated with PLFS. 38 of 102 PLFS patients agreed t o referral for psychological study. As Table V1 reveals. they were with few exceptions representative of our PLFS population. Males. concussion patients. and secondary endolymphatic hydrops arc slightly over-represented in the sample as compared with the total population.

Table VII summarizes cognitive test results in PLFS. A two-tailed Student's !-test compared the patients's group mean to normal scaled score averages (Buros. 1087). Comparison between those who had not loss consciousncss. c.g. Classes 1 to 4 (n=27) and thosc with LOC (Classes 5 to 7; n = l l ) failed to show any significant difference.

For PLFS patients. the level of intellectual function was in the average rangc (WAIS-R. FSIQ=Y1.54; VIQ=Y1.87; PIQ=04.20). Digit symbol (p<O.OoI) . Block Design (p<O.(H)I) and Picture Arrangement (p<O.OOl) scaled scores were in the impaired range tests which involved visuopractic-analytic speed tasks.

Memory data, viz. registration. retention. recall was intact for common information. geometric designs, and numbers (WMS Information. Digit Span, and Visual Reproductions) respectively. Auditory recall (Logical Memory) and Paired Associate Learning scaled scores were in the defective range (p<O.OOl) . On a test of auditory lcarning and recall (ALVV7' 15 common words repeated over five trials), all trials were defectivc (p<O.OOl).

Absence of confabulations but loosc o r tangential associations suggests dcficiency at the initial registration (entry) level. Auditory information rctaincd and recalled was accuratc but limited in amount. Visuopraxis in timed Trailmaking Test data rcvcaled accuracy but slowness (p<O.OOI A and B). suggesting inefficiency. e.g. visual scanning and perceptual-motor speed.

PLFS patients had significant losses of adaptive psychological function. 7kst data sup- ported a constellation of symptoms including: impaired short-term auditory registration and

Table VI. Characteristics of psychological sample

Psychological subset Total PLFS population

n Males Females Average age Female : Male ratio Diagnosis of PLFS (weeks) Bedrest: Surgery ratio H ydrops No LOC : LOC ratio

38 17 21 35.9 1.24 72. I 1.53 45% 2.45

I02 38 66 35.5 1.74 75.x 1.4x 38%" 2.34

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PLFS dejined in mild head trauma 23 ~~ ~~

learning. and defective behavioral efficiency (visuopractic. perceptual motor speed. complexity). Results arc statistically significant and relate to subjects’ complaints common to PLFS, such as forgetfulness, clumsiness. task fatigue. poor concentration. and distractibility accounting for the use of memory aids).

Aj~ecrivo .sympioms in PL FS

Psychologicd . emotional. and behavioral complaints o f PLFS patients included perceptual distortions in patterncd environments or when presented with complex optical flows eliciting fatigue. anxicty. depression, and uncxpl;iinnblc dread. Table VIll summsrizcs PLFSD diwr- clcrs o f affect. Primary mood complaints o f 38 patients included anxiety (23), confusion (IS). clcprcsion ( 11) and irritability ( 1 1 ). SCL-YO-R scaled scroes were statistically significant for wb-xxlc\ Sornatization (p<O.OOl ) and Obsessive (p<O.OOl) suggesting endorsement o f phy\ical problems (headaches. nausea. dizziness) and uncertainty in task performances (obsessive). Minnesota Multiphasic Pcrwnality Inventory (MMPI) averaged profiles were

Normal PLFS Significmce It me ii n > n1c;111\ /-VLilUC\ / J -V i l lUc

W’/IIS-R I . Q . Full \c;llc Y Ill0 Verh;il Y I00 Pcrformance I 0 I 0 0 Verbal tcbh

0 10 I n f o r ni ii 1 I on Iligit spiin I’ I ( I Vociibuhry 10 I 0

(’om prehension 7 I 0 Arithmetic I’ I 0

Similiiriticb 12 I0

Picture complction X I0 Picture arrangement 12 I0

t’erforniancc test5

Block dcsign 15 10 Object assembly 7 10 Digit symbol I 0 I0

W d d r r Mcwiory Scult, K;iw score 13 61.X9 Information I4 5.56 Mental control 13 6.75 Logical memory I9 7.99 Digit span 15 I I . 0 2 Visual reproduction I0 10.09 Associate learning 13 i5.4n

Hey AirrlIo Vrrbul Lmrning: n = Y Trial 1 7 . 0 Trial 2 10.5 Trial 3 12.8 Trial 4 13.2 Trial 5 14

Trail Muking: n=20 Part A (seconds) 32 Part B (seconds) 69

01 .Y4 Y I .x7 Y4.20

X.(HJ X.Y5

IO.OU x . ‘0 X . I I x . xo

9.79 X.X6 x.57 7.50 7.43

54.52 5 . 5 0 5.7x 6.37

10.46 9.37

I I .65

5.2 6.9 X.3 9.2

10.2

51 I03

3.07 3.56 3 . l h

5 . 2 0 1.x: 0.0 2 .Yh 5.70 I .xo

0.24 I .XY 3.61 5.35 6.39

4.6X 0.42 2.7x 4.85 I . I 6 I .65 5.26

4 . in 4.72 4.84 4.75 4.07

5.26 5.23

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24 R . J . Grimm et ul.

judged valid (patients' scores vs. averaged raw scores by scale). Clinical scales 5 and 10 are omitted from the minimult version. Clinical scales 1-4 and 6-8 were all statistically significant ~(p<O.OOl). These elevated clinical scale scores support a high degree o f endorsement o f psychological symptoms including somatic, deprcssive. anxiety and confusion-all indicative of significant distress. No profiles characteristic of hysteria or malingering were found. Thcsc data are consistent with PLFS patients' complaints of anxiety, frustration. stimulus intoler- ance. avoidance behavior. excessive worry. fatigue. confusion. and acute strcss.

PLATFORM VS. TYMPANOMETRIC FISTULA TEST

Which was more accurate: the older tympanometric (Henncbert) fistula test or the recently introduced platform fistula test (Black et al.. 1987)? The question o f relative test sensitivity arose almost from the day platform fistula testing came on line in our laboratory. The platform test indicated fistula twice as often as the tympanometric test. suggesting that fistulas were more common than heretofore recognized and could he associated with relatively minor cranio-cervical trauma. Even more startling was the finding of bilaterally positive tests. Was the platform fistula test too sensitive or the tympanornetric tcst too insensitive? As both tests were used. and as a number of PLFS patients failed bcdrcst and eventually went to surgery. the matter could be dccidcd by direct inspection.

Table IX contrasts the accuracy of each test and also the occurrence of SNHL i n 65 first ear tympanotomies for 44 PLFS patients. 20 o f whom (44.4%) had bilateral fistula (roughly the percentage for thc entire PLFS population). After establishing and videotaping thc presence or absence of a fistula at surgery. fistula tcst data were rcchccked t o see how each test fared as a predictor of fistula. Of 65 fresh ear tympanotomies (39 right cars, 27 left ears). h l fistulas were seen. There were 4 'dry taps' (no fistula secn) 2 of which revealed middle car

Normal PLFS Sign if ica nc'c means means c-Valucs p-valuc

SCL-90-K: n=36 Somatization 5O.OM) hS.2U 10.33 0 p<O.(HM)I Obsessive 5O.ol) 6l.3Y 7.06 0 p<O.OWI Interpersonal 50.0() 48.12 l . l Y /'=O.X2U Depressed 5O.(W) 50.65 0.41 p = 0.6U45 Anxiety 50.OO 40.94 0.03 p=O.Y763

Phobias SO.(HI 54.34 2.10 p=0.0437 Paranoia 50.00 4U.Y.l 0.61 p=0.5461 Psychoticism 50.00 50.02 0.02 p = (1. Y x42

L Scale 4.00 4.36 (1.09 p=0.03296

K Scale 14.(H) 15.15 2.66 p= 0.01 2 1

Hysteria I7.(Io 34.61 22.62 p<O.IW)OI Psychotic deviate 19.00 25.39 8.37 0 p<o.ooo1

Psychasthenia 24.00 36.16 x.77 p<O.(KK)I

Hostility SO. o ( ~ 54.15 2.OY \J = ( ) ,0447

MMPI: n=33

F Scale 3.OU 6.52 5.9x 0 p<O.OOOI

Hypochondriasis 11.00 24.30 15.38 0 p<O.OK)Ol Depression 17.00 33.85 17.(to 0 p<O.(KIOl

Paranoia 8.00 13.76 10.90 0 p<O.(KM)I

Schizophrenia 22.00 40.12 12.37 0 p<O.o(H)I Hypomania 17.00 19.3Y 2.44 p=O.O204

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PLFS defined in mild head truumu 25

pathology. viL. fibrous tissue in the region of the OW (Patient 178): and incus and stapes dis- placement with hairline fracture between RW and jugular bulb, and dense mucosal hands from the stapes to the promontory (Patient 1.52).

Platform fistula test data were available for 54 o f 6.5 explored car\. Three test results were read a s 'questionably positive' and 8 tests not completed (paticnts fcll) were excluded. Tym- panometric fistula test data were available for 58 o f 65 cars with three tests read a s 'questionable' and 4 tests not completed ;is patients became ill. Parenthetically. for all ears with incomplete o r questionably positive te\t ( I 1 platform-tested ears; 7 tympanometric-testcd cars) a fistula was seen at surgery in each case.

Test sensitivity i s the probability that ;I test will be positive when the disease of interest i s present (Kcmington & Schork. I Y X 5 ) . Specificity i s the prohability that ii test will be negative when the cliscase of interest is absent. As tympanotornie+ were o n l y carried o u t i n symptomatic car\ in which pliitforni tests were positivc. n o d a t a o n ywcificity were collected.

For J X platform fistula tcst-po\itivc cars, 44 fistulas were found ;it surgery. giving i i test sen- sitivitv of 02"h (46/46+4). When this calculation was repeated to include the X patients who fell during testing (;ill o f whom had fi\tula). the adjusted sensitivity score row to 93"L. 'There wcrc 1 .drv t;tps' in 54 pliitforni-tested ears. giving ;I BFP o f 7.47,: other middle ear pathology wiis found i n '7 o f 4 non-f is tula cars. 'I'hc HFN for the platform test was also 7.4'%,.

Using the wnic ciilculation. thc tvmpiinomctric fistula test predicted 32 o f 58 fistula with a BI'N=40.7'%, arid ii BFP=7.4'%,. The tvnipiinometric fistuln test scn4tivity = 5Y.2'%, ( 3 2 32+22) , revealing this test to be a n inaccurate means of ruling o u t a fistula. However. when uniimhiguously positive, i t predicted 9 of I0 fistulas found at surgerv.

When thcsc t l ; i ta ;ire comparctl. the pl:irform fistula test i s 33% more sensitive than thc tvmpanonictric test. predicting Y o f I 0 fi\tulas found ;it urgerv. When either test is positive. tmth arc equally scmitivc f o r the presence o f :I fistulii. However. when the tympanomctric fistula tcst was nepitivc. i t mished 4 o f I 0 fistul;is present ;it surgery. Interpretation of HFP po\itivc result5 ih \omctinics complicated by the fact of the long interval between testing and stirgcry.

HEAKINC; I -OSS IN PI.FS

S N H L docs n o t dways occur with ;I pcrilyniph fistul;i (Kohut et al.. l Y 7 Y : Singleton. 1984). ; in cibscrvation confirmed in this study with the demonstration that SNtIL was present in

Fistula Fistula not Fist + Fist + Fist - Fist - Question- Incompetc <)hwrvcd ohwrvcd Tot + Tc\t - Test t Test - ;ihle testY test'

-. I . Platform test

4

> > Right ear 34 J 27 - - J I

Lcft ear '7 1 9 - - 4 Tcst scnsitivity = 92%

I I. Tyrnpanomctric tcst

- 7 - 7

- 7 Kight car 34 4 I X 13 4 1 - - Left ear 27 14 0 - - - 7 - 7

Test sensitivity=5Y% 111. Sensorincural hearing loss

Right car 34 4 IS I9 3 I - - - Left car 27 I 0 17 - - - -

Test sensitivity = 4 1 '%)

Fistula found at wrgery in all case\

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26 R. J . Crimm et al.

only 53% of our total PLFS population. Of 44 patients in the surgical treatment group, SNHL was only recorded in 25 patients (56.8%), 15 of whom revealed bilateral losses. Perhaps the most useful observation was the demonstration of SNHL in only 25 of 61 surgically confirmed fistula ears (41%). For the non-surgical group SNHL was slightly less preva- lent (48.3%). Where SNHL is found. there was a 89.3% chance that a fistula was present. However, its absence provides false security because SNHL has a low sensitivity (251 25+36=41%; Table IX).

While the yield of posifive platform, tympanometric and SNHL tests are roughly similar i.e. 92% vs. 88.9% vs. 89.2%, in their ability to predict fistula, i t is the relative insensitivity of the older tests that is noteworthy.

TREATMENT OUTCOME

PLFS outcome analysis was difficult. Criteria for analysis are arbitrary when measured against symptom disappearance, resumption of recreational pursuits. recovery of cognitive skills, and return to work. Strictly speaking, no PLFS patient made a lo()% recovery. when such measures were pressed in detail. Further, where a secondary endolymphatic hydrops had developed after surgery (Potter & Conner, 1983) or from any other complication. one speaks of symptom control, not cure. Patients could do well for months. and thcn aftcr an intercurrent infection. seasonal allergy, or other change in body physiology. experiencc :I re- crudescence of symptoms, usually temporary, unless coughing. lifting. sneezing, or vomiting events had reopened a fistula.

Six-month or longer post-treatment data was available for 72 patients who became statio- nary. Arbitrary functional outcome grades were independently assigned by the senior author as follows: A = ExceNenr (5 points) outcome. The patient had returned t o work. virtually asymptomatic with resolution of headaches. disequilibrium. tinnitus. and perceptual difficulties. B = Good (4 points) outcome. The patient had returned to work but with some lingering difficulties, usually managed by avoiding symptom-provoking situations. C = Fuir (3 points) outcome. The patient was not working but reported symptom improvement with treatment. D = Poor (2 points) outcome. N o change; the patient was not working. remained symptomatic, and had not responded t o treatmcnt. E = Worsc ( I point) outcome. Patients were sick, more symptomatic. and not working.

Table X also compares this subset of the population with the total PLFS population, rc- vealing that a slightly greater proportion o f conservatively treated patients and thosc with secondary hydrops were in the follow-up group. There is a roughly 20% chance o f achieving an excellent result with current PLFS therapy and a good-to-excellent outcome in 70% o f cases (adding grades A and B). The average outcome grade for patients reaching h months or more was 3.73, a B minus. about the same level as previously rcported (Black et id . ,

1987).

PROGNOSTIC FACTORS FOR PLFS TREATMENT OUTCOME

Fig. 10 was constructed from a discriminant analysis data sort in which outcome grade was tested against 7 variables. Were any of these factors of prognostic significance’? From 200 separate analyses, the 20 highest scores >4.0 (4 .04 .67: Grades B to A-) were distributed across the listed variables and contrasted with the 20 lowest scores 4 . 5 (2.67-2.43: Grades C- to C+) giving the histogram shown. Ordinate values represent the actual number of times a grade was recorded for the designated variable. For example, for those graded A or B, age ~ 3 0 turned up in 10 of 20 calculations but in only I of 20 calculations for Grades C to E which were weighted toward the middle-aged. Not having been unconscious (prcsum-

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PLFS defined in mild heud truuniu 27

12

10

8

Frequency of

Occurence 4

2

II <30<40<6OzgO Poa.Neg. U d B U . 1&23h45&67&8 B 9 4 2 262 P M

lrge Hydrop FLtulPe Injury Class Treatment Dx Week Sex

Variables

m m Grade. 2 "B" Grade. < "0" (4.0-4.6n (2.67-3.43)

11-51 II-21

ably le5s severe t rauma)tr having ;I unilateral fistula. craly diagnosis. and no complications (e .g . hydrops) ;ire factors associated with ;I more favorable outcome.

For A-grade outcomes. the general trends from the J i w i m i n a n t analy\is were borne out : 13 A-grxieii patient\ trciited with liedrest alonc camc from C'l:i\s I and 2. e.g , without hcadstrikc o r concussion. Of A-grade outcome wrgical patients. 7 o f 13 had a single car fistula repair. with ;I revision (second operation) on the same car only done in 2 paticnts. Sec- ondary hydrops wtih negatively correlated with outcome: i t was found in only 4 A-graded paticnts (30%) ;is contrasted t o 50'%, in B grndcs and below. In general, the worse the injury. the longcr the time t o diagnosis. and age greater than 35, the greater the likelihood o f hilat-

I . f'opidurioii ('Iiurtrc.ttvivrii.c

>6 m o n t h 5 ziftcr trcatrncnt i C'onscrv;itive outcornc =?2.3?X.O months ?Surpic;ll outcornc = 35.5+ 12.7 mon ths

I1

S Age Fcni;ilc : M d c ratio Diagnostic wcck Injury class pcrccntagcs

I & 2 3 & 4 5 & 6 7 & X

Fistulae-Unilatcral : Bilateral 'Treatrncnt-Conservative : Surgical Hydrops-Prcscnt : Absent 11. Grude

n A =Excellent: 13

C = Fair: 14 B = Good: 3x

Outconic Analysis Group 77 35. I I .hJ 7 3 . 0

33 3X 25 J 0.46 1 .Y4 o.nY

D = N o Change: E = Worse:

'Tot;il Population I02

1.75 75.8

3x.z

3( 1 3 0 2s h 0 .43 1.30 0.63

n 5 7 -

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era1 fistula and the development of a secondary hydrops. Such factors militated against a favorable outcome with current therapies.

Predictors for secondary hydrops included surgery (40.0%, hydrops vs. 29.3% hydrops in the bedrest group); concussion (Class >4) = 77.3% of those with hydrops vs. 44.8% <Class 4; chronicity: 42.9% with diagnosis > I year vs. 30.7% < 1 year; and heing male, viz. 2 : 1 male to female, irrespcctive of etiology or whether or not surgery was rcquircd).

Discussion OVERVIEW

In the universe of head trauma there exists a suhset o f patients with inner car injuries which can he defined and treated. The question is how to recognize them and what t o do about it. Who would have hclicvcd that such injuries can arise from a whiplash alone. Until the advent of platform technology. the study o f vestibular injuries has been esscntially ;I study o f vestihular-ocular interactions induced either hy controlled rotational movements or from external canal stimulation. Rupture of the membranous windows o f the otic capsule could o n l y be known for sure by direct visualization at tympanotomy. A positive tynipnnomctric fistula test o r the presence of sensorineural hearing losses while useful i f present in sick. vertiginous patients are often negative findings in the chronic PLFS patient. missing perhaps SO'% of the fistula prescnt.

With the advent of the controllahlc platform. the conwquencch o f a lahyrinthinc injury can he studied from the point of view postural dyscontrol. and. hy deploying precise cxtern;il pressure modulation. a search also made for an cvokcd pathological coupling translating as quantifiable sway in the presence of a fistula. Such posturography mcthods have consider- ably improved our understanding of the role of the labyrinth in postural control. augmenting the capacity o f the older Cawthorne-Hallpike mancuvcr t o identify canal dysfunction such a s

BPPN. here identified as the companion lesion to the perilymph fistula in PLFS. Thus, for both lesions wc have a laboratory definition which i n conjunction with VOK tcst-

ing. electrocochleography. conventional ENG and calorics not only identify PLFS. but also help to rule out other pathologics. or suggest additional complexities, e .p . endolymphatic hydrops.

A second general issue which has overshadowed all of th i \ work has hccn the prohleni o f the post-concussion syndrome. raised immediately for all chronic patients with ;I history o f a headstrike or a brief, documented LOC. We havc not made a systematic study with EEG. MRI , and hrainstcm cvokcd potentials in all of these patients (to rule o u t markers o f organic insults). A proper, prospective study would do this. We (or previous attcnding physicians) havc used such tests in perhaps half of our Class 5-8 patients (LOC) with uniformly negativc results. The extraordinary cxpcnsc o f such a scarch on other grounds is flawed. not for i ts intcrcst in positive findings, but as in its negative findings, viz. a negative finding docs not rule out a subtle, diffuse brain injury from angular accclcration forces with or without LOC.

In general, we provide a tertiary consultative neurology and neuro-otology service with ii

specific interest in so-called 'minor' head injuries. including whiplash cases which dwindle. As it did not secm to matter whether or not there had been a headstrike or even LOC with respect to the development of PLFS (especially in women). i t raised important questions about the nature of the sample of accident victims we were seeing. For chronic post-concussion or equally chronic whiplash patients, what proportion carry vestihular injuries'? Such issues, together with the association of cognitive and perceptual difficulties in a defined vestibular injury dominate the discussion which follows.

Vertigo from head injury, described by Galen. has counted among its sufferers Alexander

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the Great, Captain James Cook, and a former American astronaut. It is a relationship known to all physicians and to all head injury and whiplash victims. given a little latitude to the word dizzy. More than a decade age. Healey et al. (1976) described the presence of positional nystagmus in pcrilymph fistula paticnts. and exhorted all physicians to remember the labyrinth's vulnerability to any trauma. a position re-emphasized in the New Englund Journal of Medicine in 1982 (Healey. 1982) and here in our own vork. We have confirmed the observations o f tka ley and his colleagues. and also those o f Cartlidge & Shaw (1981) who described labyrinthine losses in their hcad-injured patients and recognized that such dysfunction was somchow linked to cognitive disturbance. Their review o f the interrelationships between head injury, labyrinthine deficits. and post-concussion sequelae was invaluable.

Our work began in thc late 1970s with a curiosity ( R . J . G.) about the persistence of stiff neck and headache in whiplash patients months and sometimes years after what had seemed at the time t o have been a minor injury. By 1982. i t was clear that the problem lay with the program for controlling neck muscles and not with neck muscle structures per se. By 1983. we knew that such patients (including the mildly head-injured) had labyrinthine deficits with symptoms triggered by or exaggerated in perceptually complex situations and that such injuries by mechanisms unknown interfered with first-order cognition (in the absence of data supporting ii diffuse brain injury). By 1984. the broad outlines o f PLFS had been clarified. From this work, selected issues iire given t o discussion. Case histories for both acute and chronic PLI-S ;ire provided i n the Appendix. together with a more formal review o f the pathophysiology of perilymph fistula and canal injuries.

A NATURAL HISTORY OF PLFS

From ;I tr;iurnatic cvcnt subjecting the head t o 4gnificant linear or angular acceleration. with or without LOC. otic capsule windows rupture and otoconia are dislodged from the utricular niacule, producing a spectrum of symptoms with vertigo. hearing loss. ataxia, and vomiting at one end o f the spectrum. and disequilibrium. nausea. and tinnitus at the other end. There i \ often ii history o f prior cranio-cervical trauma.

Acute symptoms abate. but tinnitus. cpisodic niiusca and disequilibrium persist: frank SNHL (charactcristically o f lower frequencies) occurs in roughly half the cases. Stiff neck and cervical-contraction type headaches dominate the chronic phase; there may occur additional headaches reminiscent of migraine without auras. A subtle loss of first order cognition slowly enters awareness. On return to work, undiagnosed PLFS sufferers find they have lost effectiveness. It takes longer to d o tasks. t o learn new things, and short-term memory is unreliable. especially with distractions. Physical and mental effort are doubled just to reach prior levels of performance. Fatigue. neck stiffnes. and tension-type headaches increase against a background of low-level disequilibrium, tinnitus. and intermittent nausea.

In time, odd experiences with elevators. rcvolving doors. traffic. recreation, and crowds accumulate. Imperceptibly, social behavior changes to reduce encounters with provoking situations. Some patients become agoraphobic, a phenomenon previously linked to vestibular injury (Marks, 1981; Jacob et al., 1985). Others throw themselves into their work, collaps- ing at the end of the day. For all, there is a gradual functional decline whatever the vector or measure. This phase reaches a steady state, with symptoms precipitated by barometric or intrathoracic pressure changes e.g. flying, travel to the mountains, coughing spells, and even elevator rides. symptoms are controlled by unlearned by powerful shaping processes, in part directed by the external environment, e.g. practiced avoidance of certain provoking situations. The condition fluctuates and persists for years as suggested in follow-up studies of vertigo after head injury (Bergman & Frederickson, 1978). probably a combination of unresol-

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30 R. J . Grimm et al.

ved BPPN, hydrops, and intermittently open fistula. Patients survive by adaptation. avoidance, and a major change in their lifestyle.

BEDREST

A prolonged brief bedrest of 6 weeks is the backbone of our initial therapy for PLFS. As a therapeutic venerable, i t was revived (WGH and FOR) iis a relatively inexpensivc and con- servativc but effective method of treatment of the fistula component o f PLFS. By trial-and- error, it was found that brief periods of bedrest o f 1-2 wccks were empirically not as effective as 6 weeks (FOB, per communication). Not only did i t make physiological good sense. hut where bedrest was successful, it prcvcnted unnecessary surgery. I t is not ii simplc treatment. It may be an impossibility for some. e.g. single PLFS women with children. those without a supportive family, and in the U.S., those without a supportive private insurance carrier t o pay for in-homc household management while strict bedrest i s achieved.

Bedrest is not without its own risks. e .g . elcctrolytc loss including calcium (within 3 days). thromboemholism. disusc muscle change. loss of appetite and constipation. altcrations in im- mune system. and unpleasant mental effects. c.g. borcdom, anxiety. anger. and depression (Brody, 1Y8X). In practice these complications are uncommon and most people. including the elderly. tolerate bedrest well.

An inability to comply with 6 wccks o f bedrest was often the cause for treatment failurc. Collagen healing rcquires 6 t o 12 weeks for fractures and sevcrc sprains. ii period in which skin achieves only a 50% recovery o f tcnsilc strength. For the inner ear. bone and soft tis\uc collagen does not heal as well or as rapidly :is apposition o f two segments o f soft tiwtc collagen. The ossicular chzin is in constant motion relative to the otic capsule and thcrc is a coti- stant pressurc differential between the fluid spaces of the inner ear fluid spaces and t ranwnt pressures i n the middle ear. Other factors contributing to bedrest failurc included dcl.iy o f diagnosis. over the age of 30. a higher trauma class. and thc development o f secondary cndo- lymphatic hydrops.

PLFS FROM WHIPLASH

Pcrilymph fistulac are not always associated with violcnt traum;t. They can occur \pontanc- ously (Healey et al., 1976). during a hard crying spell (Seltzcr Kr McCabe. IY8h). strenuous exercise (Stroud & Calcaterra. 1970; Goodhill. 1071 ). diving (Frccmon Cyr Edw;irds (1973). bouts of sneezes. coughing, or laughing (Strohm. 1986). descent in a commercial air flight (Seltzer & McCahe. 1986), exposure to the dischargc o f ;I magnum revolver (Goodhill. 1Y80). tearing out bushes in the garden (Strohm, 1986) and the stress of receiving bad news (Kohut et al.. lY7Y).

Angular acceleration (center of rotation i n the lowcr cervical spine) is more productive of injury than translational acceleration (head movements along a straight line; Ommnya & Hirsch, 1971; Ommaya & Ciennarelli. 1Y74; Ciennarelli et al.. 1082). I t is no surprise. then. that whiplash forces on the otic capsule appear sufficient t o produce PI.FS. Healey (lYX2). citing his own observations. noted that 50% of whiplash patients reporting vertigo have lahy- rinthine damage; Rugin (1973) reported that 10 to IS'% of such paticnts may have a sensorincural hearing loss (1073).

LABORATORY TESTS FOR PLFS

How valid are the laboratory test upon which our PLFS samplc was defined? At the heart of this work is the Nashner platform, a powerful quantitative toll designed for the analysis of

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the metrics and structure o f postural responses t o controlled perturbations. Here, the platform was deploycd to study vestibular damage in the head-injured. e.g. cupulolithiasis and t o also search for perilymph fistula. I t confirmed the previously published accuracy of the platform fistula test (Black et i l l . , 1987). and also gave thc surprising finding that bilateral fistula in the head-injured may be the rule rather than the cxception.

On the question of positional nystagmus in PLFS. wc pursued the same diagnostic stra- tegy, i.e. pairing an older. standard clinical test, viz. the Cawthornc-Hallpike mancuver. with platform posturography. All PLFS patients revealed serious balance problems, quantitatively marked; 70'% o f PLFS patients gave classical response5 to thc head drop of the Cawthorne- Hallpike miineuvcr a s detected by visual inspection and ENG recordings. Conversely. platform posturography trials were uniformly abnormal in all PLFS patients when deprived of visual information (Black & Nashner, 19x3, 1984: Rl;ick. 1985). Our conclusions based o n these comparisonc were similar t o those for fistula tests: thc older Cawthornc-Hallpike test is useful but relatively insensitive. Platform posturography is the superior tool.

A R E P1.FS AN11 C'tiRONIC POST-CONCUSSION SYNDROME T H E SAME?

Most o f o u r chronic PLFS patients with ;I LOC had been previously labeled a s having a post- concussion \yndromc before we saw them. ' I h o x with identical symptoms from cithcr a headstrike and whiplash. or whiplash alone, were occasionally placed i n the same category. but were more likely (cspeci;illy where o n l v whiplash was identified (c.g. our Class 1 cate- i p y ) t o have one o f three less attractive diagnoces i n their medical rccords. viz. malingering. hvstcriii. or the suggestion o f a compens;ition neurosis. the latter often stated with less ob- lique 1;ingiiugc. As i t turned o u t . there were o n l y three f;ictors common in the medical records of all o f o u r PI.FS patients. regardless of heiid injury class: complex. persisting svmptoniology in patients who \lowly lost the ability t o function. and a history o f what had appcarcd t o their phy.;icians a s ii trivial injury.

Po.;t-concu\sion \yniptoms tend to linger (1)enkcr. 1944: Rutherford ct al . . 197'7) and. as we have shown, resemble those o f chronic P1.FS where 'dizziness' means disequilibrium and SNHI. I S iihsent o r muted but tinnitus persists. In talking about their persisting effects, the ncuropsychologist Binder had this t o say about the definition o f post-concussion ( 1986):

*'. . . it term reserved for patients who have persisting subjective symptomology resulting from cerebral concussion. The common symptoms include headache, dizziness. irritability. anxiety. blurred vision, insomnia. fatiguability. and concentration and memory difficulty."

All o f the symptom5 mentioned are clustered in PLFS and their natural history is similar, i.c.. for many. persisting for months or several years.

As an cxcrcisc, and because the subset of paticnts we elected to study (most o f the chronic Class 5-8 patients with a diagnosis of post-concussion) all had PLFS by laboratory definition. the question could be asked: could chronic PLFS and chronic (unresolved post-concussion syndrome) he one and the same'? Indubitably. PLFS exists as a subset o f chronic post-concussion syndrome, and on other grounds. i t is equally likely that lesser amounts of unrecognized labyrinthine damage co-exists with post-concussion. e.g. a compensated BPPN. As we have shown, LOC or even a headstrike are not critical variables for PLFS. This being so. the above exercise would suggest that those cognitive and perceptual difficulties (to say nothing of the issue of 'dizziness') which crop up in the post-concussion syndrome may not be linked with any brain damage per se but instcad might be entirely accounted for by an unrccog- nized, serious labyrinthine insult concealed by visual compensation and other strategies: that in fact, until proven otherwise. chronic post-concussion syndrome, especially where the in-

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jury of record does not appear to match the complexity. chronicity, and dysfunction (especially where the case for serious brain damage is weak) and PLFS may well be identical.

In passing, it should also be mentioned that LOC need not derive from a headstrike. It can arise from ‘passive’ angular acceleration (impulse) forces alone (Ommaya B Gennarelli, 1974; Gennarelli et al., 1982). Therefore, the hypothetical identity of PLFS and post-concussion could rest on the consequences of angular acceleration forces alone on the otic capsule. a point bolstered by our finding of no significant symptom differences between our concussion (Classes 5-8) and non-concussion (Classes 1-4) PLFS subsets.

A labyrinthine role in concussion has been cited by others (e.g. Toglia et al.. 1069; Cart- lidge & Shaw, 1981; Healey, 1982). Cartlidge & Shaw’s findings are of particular interest as they provided an additional bridge, viz. the connection between labyrinthine injuries and cognitive difficulties (p. 126):

“It transpires that impairment of concentration. anxiety, and in particular hcadachc were all encountered more frequently by thosc with dizzinesb than thosc without i t . ”

BPPN was found in 29 of 72 of their patients at discharge (40.3‘%). Thcy concluded that post-traumatic dizziness arose from injuries to peripheral labyrinth and with it hcadache and cognitive disturbance. PLFS may have been present in some of their patients. cven thosc without vertigo (as concealed by visual compensation).

R. J . Grimm et al.

PERCEPTUAL DIFFICULTIES AND COGNITIVE LOSSES

The most startling findings in PLFS are the cognitive and perceptual troubles. We do not know if they stem from the BPPN component, the fistula. or their combination. But they arc universally present, provoke serious worries in the PLFS patient, are usually unspoken- especially as time passes-and we assume arc some outcome of persisting vcstibular distortion in combination with the mechanisms underlying visual compensation. Such difficultics appear to arise (or are at least more easily recognized) in the period of stabilized deficiency and appear linked to visual compensation. The role of optical flow for stance control (Stoffre- gen, 1986) or the articular mechanoreceptors of high cervical spine (Wyke. 1967) and the cervico-ocular reflex remain undefined. The relationship between memory loss and hcad injury is a function of injury severity, interval between testing and injury, and task (Dikmen et a l . , 1987). To our knowledge, there is no earlier literature linking defined labyrinth injuries from mild cranio-cervical trauma, with neuropsychological test data. I f confirmed. o u r uncontrol- led findings would offer the hope of recovery for some of these patients.

In passing, we recognize a scattered literature which has focused on aspects of vestibular disturbance and behavior. For example, a relationship has been drawn betwecn vcstibular disorders and anxiety (Pratt & McKenzie, 1958; Bastecky ct al.. I Y X I ) , a relationship amply documented in our own study. Further, Werner et al. (19x3) noted some connection with psychoses, and linkages drawn to emotional distress (Hallam B Stephan, 1985). dyslexia (Levinson, 1984), phobias and panic attacks (Levinson B Carter, 1986) as well as with an agoraphobia (Marks, 1981), the latter confirmed in our own work. Such observations il- lustrate a lively interest in the role of this old sense organ in emotion. cognition, and learning. As we have seen in all of our patients. there is something fundamentally disturbing to one’s emotional and intellectual stability when labyrinth physiology is chronically disturbed. At this point in our studies, what does PLFS tell us about the brain’s response to erroneous sensory information from the vestibular labyrinth?

es: (1) A disordered gravity reference and/or erroneous head movement signals preclude reliable cognition when spatial orientation mechanisms are

Here are some tentative possib

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disrupted. For bipeds, it is balance before reason. (2) When coupled t o labyrinthine deficits, performance of intellectual o r moto r sequences falters; glitches a re common. (3) Learning and accommodation t o new o r novel information is inefficient when the labyrinth is disabled, a source o f a la rm, frustration, and depression. (4) After a labyrinth is damaged, cognitive disorganization is linked t o visual Compensation, marked by a peculiar interference with the eye movement program for reading. (5) Functional recovery appears t o be initially ignored by brain as cognitive recovery lags. Brain seems to need a level of assurance before returning b;tlance decisions t o a previously injured labyrinth. Incomplete resolution of BPPN or secondary hydrops blocks return of intellectual sharpness.

PLFS is a program disorder o f movement (Gr imm, 1983) presenting the CNS with enough distortion t o induce a compensatory visual override. the price being cognitive disorganization and the need t o avoid visually complex situations. Tha t i t may be the o ther way round in learning-disabled children (Shumway-Cook et a l . , 1987; t to rak et al., 1988). viz. intellcc- tual disorganization adversely influences scnsorimotor integration from vestibular information is ;ilso known. In cithcr case, distorted vcstihular information or disorderly processing of probably normal vcstibular information can be functionally dcvastating.

Acknowledgements Thc ;itittior\ ;ire gratcful for computer and data handling as5istancc o f Mr David C. Percy and to critical manuxript review hy Dr N;incy Grimm. Dr Charlottc Shupert and Susan Pcsznecker. Illustrations were prcpared bv I.isa Million. Our special thank\ to the technical staff o f Good Samaritan Hospital’s Neuro- Otologv I-aboratory. Cirirnt wpport f o r computer and data processing was furnished from NIH Grants iY222, t)r F. Owcn Bl;icL, Principle Invcstigator.

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Appendix CASE HISTORIES

Acute PLFS patients arc sick, nauscatcd, and unsteady. they are a little disorganized and complain of ear ringing and vcrtigo. This is an ED diagnosis and requires immediate otological consultation.

In the consulting room, chronic PLFS rarely points to the labyrinth. There may bc no SNHL or vestibular ataxia. Tnnitus, vertigo. and nausea may all be cpisodic and they arc characteristically obscured by headache and a stiff neck. complaints usually described as worsened by exercise. If there has been LOC, a post-concussion diagnosis has probably already been given. PLFS patients recognize a decline in mental crispness and work performance. These symptoms as well as more arcane cognitive and perceptual difficulties are only un- covered with a detailed history. Inevitably, there is an insidious retreat from family life, increased marital stress, and depression occasionally to the point of suicidal ideation. Nine cases are presented to give a perspective to the clinical history. symptoms, and signs in the acute and chronic forms of the disorder.

Acute cases

Case I: David G., a halfback on Portland State University’s football team, was seen in the ED in March, 1985 30 min after falling from the high bars at the gym with a brief LOC. In the ED he was alert, organized, nauseated, and complained of tinnitus and dizziness. With the exception of loss of tandem walk and heel-toe stance, the neurological examination was normal. A preliminary PLFS diagnosis was made. Both fistula tests were positive for both ears as were BPPN tests; the audiogram was normal. PLFS symptoms improved on bedrest and BPPN symptoms cleared with PT. He recovered completely and returned to school in September, 1985. Head injury: Class 5.

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Crrsr 5.- Keith B . . a 32-vcar-oId steel worker. was liternllv hammered into the proud h y a Iow- crcd boom. the force crumpling his hardhat and pitching him forward without LOC. Neck stiffness and headache dominated the picture for the first 20 days most of which was spent in bed. H e felt disorganized and was unstc;idy on trips to the bathroom. Vertigo was worse with eye closure. On elevators. he described "a rush o f falling;" hcadxhe and tinnitus gradu- ;illy increased in severity. Concentration and memory were "off" and fatigue was severe. Findings ;it 4 months included brisk knee reflexes, hreakdown o f smooth pursuit upgaze eye movements, inability t o perform heel-toe stilnce or tandem walk with eyes closed. Psycholo- gical testing revealed losses in short-term memory, visual tracking. visual organization. digit symbol manipulation. and in concentration and mental efficiency. Initially, he demonstrated normal audiometry and caloric test, but a positive Hallpike test for BPPN and bilaterally positive fistula tests (both methods). Bedrcst failed. A right tympanotomy 6 months post ac-

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cident revealed a fracture of the stapes crus with both OW and RW fistula. At 9 months post- accident, a left tympanotomy revealed a dislocated stapes and OW fistula. Vertigo and nausea ceased but tinnitus remained and hydrops developed. Violent sneezing reopened the left OW fistula. The ear was re-operated, the stapes removed and replaced by a homograft. and the fistula was closed. He was left with a mixed conductive 20 dB hearing loss in the both ears. Concentration, short-term memory, and reading deficits gradually faded. By the sum- mer of 1987 he had started college training for engineering, a program intermittently inter- rupted by hydrops symptoms. In June, the left ear homograft was revised, giving symptomatic improvement. Head injury: Class 3.

Case 6: Janet F., a 38-year-old Scottish-born psychologist was injured in a MVA in February. 1986. Without warning, she was hit from behind, sustaining a whiplash without LOC. Head- ache and neck stiffness persisted. Sudden movements triggered vertigo. nausea. and worsened the headache. Most frightening were fatigue and cognitivc troubles: she could not sus- tain attention or concentration with patients. Reading was "off" and words "flitted herc and there" making i t difficult to get through a paragraph. Short-term memory was unreliable. worse with interruptions or surrounding distractions. Chronic disequilibrium was worsened by travel on elevators, escalators, stairways, and in market aisleways. She recognized mild symptoms of agoraphobia. She gave up driving as depth perception was unreliablc in traffic. When hearing in the left ear declined (coupled with occasional deep ear pain) and she found herself transposing words, neurological review was sought in January. 1987. Findings included: Weber testing (tuning fork) lateralization, OKN testing with breakdown of vertically- evoked saccades, brisk knee jerks, and loss of balancc with eves closed. Testing revealcd di- rectional. fixed, and positional nystagmus, 10 dB hearing levcl at 1 O(l0 Hz in both ears. diminished speech threshold and spcech discrimination scores. positive platform and negative tympanometric fistula tests. and abnormal posturography. Redrest healed the fistula. hearing improved, and BPPN compensated. She returned t o work 3 months later but dcvelopcd hydrops and one fistula has reopened and has not responded to bedrest. She is awaiting tympanotomy. Head injury: Class 1.

Case 7: Roger T.. a 52-year-old cabaret entertainer was attacked with a tire iron and knocked unconsciousness (few minutes) in January. 1984. Hc was taken to an ED, 72 facial and scalp sutures were placed. and he was released. Vertigo waned except for brief episodes triggered by movement or during commercial air flights. Where possible he drove by auto to engage- ments but noted vertigo when crossing mountain passes; symptoms increased with weather changes. Chronic tinnitus (cricket sounds) supervened, interfering with musical pcrfor- mances. It became difficult to learn new music and impossible to learn new lyrics. He lost a renowned ability to play the piano and converse simultaneously with lounge patrons. For- tunately he had a repertoire of over 2000 songs to draw from; old memories were not impaired. There were no decrements in timing or delivery but he dropped words from songs and faked musical phrases that had disappeared from memory. H e could not perform in rooms with geometric wall patterns. He lost balance on elevators and escalators. found it difficult to walk in the dark. and tolerance for alcohol declined. Neurological examination 18 months after the assault revealed a mild left sensory hypesthesia, increase in left palpebral fissure, and a flattened left nasolabial fold. Hearing was diminished on the left and distorted on the right. Tandem walk and heel-toe stance were difficult with eyes open and impossible with eyes closed. WAIS-R studies revealed a full-scale IQ of 121 (Verbal IQ 125, Perfor- mance IQ 111) with moderate difficulty on tests of concentration and novel, visuopractic and visio-spatial function. A sleep-induced EEG with sphenoid wing recording and CTscan were normal. Neuro-otological studies revealed positional nystagmus and bilaterally positive tympanometric fistula tests. He was too unstable for platform fistula testing. Audiometry re-

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PLFS defined in mild head truumu 39

vealed pure-tone losses beginning with a 5 dB loss at 1 (HH) Hz to 40 dB losses at hOOO Hz. He refused surgery. Bedrest reduced symptoms. but he never returned to full-time work. T n - nitus, distortions of musical sounds, inability to add to his repertoire. headaches and neck stiffness persisted. Episodes o f disorientation and vertigo remain. A secondary hydrops developed. He remains chronically disabled. Head injury: Class 7.

Cuw 8: Kathryn R . , a 36-year-old woman electronics firm trainer, caught her heel in carpct- ing in I982 and pitched down ii stairwell, knocking her unconscious. She was examined and released from an E D only to be rehospitalized ii week later for unstcadincss. tinnitus. vcrtigo. and the onset of stuttering ( a brother stuttered). Skull X-rays. EEG and CTscans were negative. She was ataxic and "fell like a log" making no attempt to catch herself during a tandem Romberg test. Knee jcrks were brisk, the right arm was slightly weak. and finger-to- nose testing (eyes closed) producing cheek touches. She was unable t o tandem walk and corn- plained of vertigo with head movement, A diagnosis o f post-concussion syndrome was madc. She was examined in neuro-otology in 1YX3 t o reveal ;i right SNHL. BPPN. and balance deficits. Fistula tests were not done (this diagnosis was not considered). Disequilibrium con- tinued. stuttering Icsscned. and she returned to modified work. although memory, new learning. tracking. and sequencing were deficient (as recorded hy company supervisors). She con- tinued i l l . with vertigo triggered by the scrolling o f her cathode ray oscilloscope (CRO) tube. On a commercial airflight in 19x4 she became suddenly i l l with nause;t and ear pain followed hy hcaring loss. Audiometry revc;iled ;t conductive hcaring loss it retracted tympanic mem- hranc. and SNHI.. Tympanotomy revealcd fracture o f the right stapes footplatc and an OW fistula which was closed. Her conductive loss hut not SNHL recovered: BPPN remaincd. As the SNHL progressed, she re-explored. rcvcaling that the fistula had reopened. I t was repaired a second time and she eventually returned t o less demanding work. Marital troubles provoked divorce. She remains unsteady and intermittently symptomatic. Head injury: Class 5 .

C'use Y: Curtis M . , a 28-year-old city of Portland utility worker. made an open-windowed ride through ;I 100 yard cloud of bromine gas blanketing an industrial roadway. The gas had escaped from a manufacturing plant. After the truck exited the could. he and the driver were at the roadside retching and vomiting for minutcs. Blurred vision. altered depth perception. burning eyes. and vertigo were additional. immediate symptoms. Other symptoms: disequilibrium. hearing loss in the right ear punctuated with occasional sharp pain. aural fullness, continuous headache. and tinnitus. Vertigo was worsened by eye closure. He was unsteady on ladders, clumsy (bumping into doorways and furniture in his own house), and lost balance on elevators and escalators. When fishing, stream motion made him lose his balance. He gave up woodworking. frustrated by a forgetfulness for the sequence of tool use. In Sep- tember, 10x6 examination revealed a slightly wide-based gait withoug titubation or falls on turns. The Weber lateralized. alternating movements of the upper extremities were sloppy. and he was surprised by tandem walk difficulty (eyes open). He fell in heel-toe stance (eyes closed). Both fistula tests were positive on the left; audiograms were initially normal. Retch- ing presumably produced the fistula; the BPPN may have come from a 1976 head injury which decompensated when he developed fistula. Bedrest failed and SNHL developed. The fistula was closed at surgery in July, 1987. The patient recovered and returned to work. Head injury: Class 1.

PLFS PATHOPHYSIOLOGY

From Strohm's comprehensive review (1984). the salient observations on fistula are these: the 300-pm thick annular ligament of the OW may be weak along its anterior edge (Althaus.

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1981: Goodhill et al.. 1981); the 20-pm thick KW (Miriszlai ct a l . . 197X) passively yields t o

labyrinthine fluid displacements c.g. footplate movement; perilymph pressures in the cat rise and fall with intracranial pressures and in synchrony with the respiratory cycle (Kcrth Kr Allen. 1953) and in the rabbit. to pressure applied t o the thorax or the atlanto-occipital mcm- hrane (Ahlen. 1973). In cadaver cats. RW memhrane displacements ot 120 pni (under 30 mmHg pressure) will rupture the membrane at the margin (Klcinfeltft & Dahl. 1070. cited by Strohm) and slow. sustained clcvations o f intracranial pressure in the ancsthctizcd cat will rupture the KW rncinbranc (Miriszlai & Sandor. 1980). Experimental fistulas heal sponta- neously in guinea p'g (Axclsson ct a l . , 1977) and cat (Simmons el a l . . 1962). 7'hc cxact mechanism of how fistulas arise f r im head blows remains elusive. Simmons ( 1079) has pro- posed inner ear membrane rupture. Fistulas may arise from prc-existing mcmhranc defects. c.g. prior middle ear infections (Knight, IY77) or congcnitiil rlcfccts (Althaus. 1077) such ;is can he present in the annular ligament (Bennett. 1966).

Excluding fractures. penetrations, and inertial force\. Goodhill ( 1980) scp;ir:rtcd fistuh origin into two categories: thnsc produced hy a head hlow o r during ;I whiplash which cffcct membrane explosions, c.g. suddcn transmission of C'SF pressure via the cochlear aqueduct and internal auditory foriimcn. and thosc from implosive forces rising in thc middle car space, c.g. coughing. diving. laughing and snec/ing. csp i l ly i f the Eustachian tuhc is plug- ged. I f intrathoracic pressure should suddcnly rise at thi\ point. window rupture can occur.

Sin;ill dimictcr long channels connecting the CSFspxx with t h c inner car operate ;I\ ;I low pass filter. This provides frictional damping to attenuate pulses and incrcasc the duration of their cffcct. Slow. sustained increases in intracranial pressure can also rupture c;ipwlc windows (Ahlen, 1973; Hiirkcr ct id.. 11~73). A leak of pcrilymph ( N a ' I40 mEq/litcr. K A 10 mEq/liter. and 7otL") nip '%, of protein) alters capsulc pressure (Miri\Aai & S;iniior. 19x0). voltages. or both to gcncratc symptoms, including thosc from diminished cochlcar niicro- phonics (Simmons & Mongeon, 1967). Finally. it is possible that head trauma p ~ r .w may

transiently deform the capsule to producc marginal tcarc of the nicmhranous window\. Finally. force differences resulting from inertia acting simultaneously upon the incus (3

mg average weight) vs. the more fragile stapes ( 2 . 5 mg irvcragc weight) might explain the frc- qucnt finding of footplate fractures and displaccmcnt ( o r suhluxations) with rupture of the annular stapedial ligament (Black. I Y X X ) .

The second injury o f PLFS is a traumatic cupulolithiasis. As originally described hy Bir iny (1921), positional vertigo (usually BPPN) is episodic. o f acute onset. and limited in duration arising from position change (start and stop) and not movement per s e . Grove (1028) suggested that post-concussion vertigo was o f vestibular origin. Cawthornc ( 1936) concluded that persistent dizziness in 58 head-injury patients was due to cnti-organ vestibular damage. This matter was studied extensively (Dix Kr Hallpike. IYS2; Stahle Kr Terins. 1965; Barber. 1973; Katsarkas 8i Kirkham, 1978; Baloh et al., 1979. Epley, 19XO). Lindsay & Hemenway (1956) and Schuknecht ( 1962) demonstrated degeneration o f structures supplicd by the anterior vestibular artery sparing the posterior ampulla. resulting in the loss of thc u t - ricular otolith membrane. Schuknecht ( 1062) reported basophilic deposits in 3 BPPN cases and Vyslonzil (cited by Epley, 1980) found displaced otoconia in the posterior canal. As the normally matched specific gravity of the endolymph and cupula is lost. angular accelerations provide a transitory excitatory input (positional vertigo) ending when the head is at rest as canals respond only to angular accelerations.

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