In the absence of complications, such as sensorineural hearing loss, treatment of active, uncomplicated PLFs should always begin with conservative treatment. About 85% of patients will improve with 6 weeks of bed rest.62 The goal of bed rest is to minimize movement across the defect causing PLF. This immobilization technique is accomplished by minimizing changes in intracranial, intrathoracic, and/or intra-abdominal pressure and is analogous to the principles of wound healing employed by all successful surgeons.
Patients placed on bed rest are instructed to recline on bed or couch with their head at or above 30 to 45 degrees elevation at all times (including during sleep) and are allowed up only for meals, and bathroom/bathing privileges. Patients are given a list of pressure-related activities to avoid, which include bend ing, straining, yelling, drinking liquids through a soda straw, and so forth.76 They may not work, perform house or yard chores, care for children, run errands, attend school, or leave the house while on bed rest. They are given a vitamin-mineral preparation and encouraged to eat a well-balanced diet and to drink 6 to 8 glasses of water each day. Stool softeners are used as needed to avoid constipation.
PLFs will close in approximately 80 to 85% of patients who have followed this regimen for 4 to 6 weeks. The likelihood of closure is inversely related to time elapsed from PLF onset; those patients with new PLFs are much more likely to obtain good closure from bed rest than are the patients whose PLFs have been present for months, or years. For successful management of PLF, early diagnosis is a critical factor for satisfactory outcome.
Although this regimen may seem strict and prolonged, our results in using it have been very good, with a high rate of return to work or ADL.62 Most of our patients have posttraumatic PLFs, and most have come to us months or years after the development of PLFs, usually as a tertiary referral. Many have undergone less strict attempts at conservative treatment with poor results. Typically, the PLF patient will self-restrict physical activities that cause symptoms, resulting in a temporary seal of PLFs with middle ear mucosa. Because middle ear mucosa contains little or no collagen, resumption of physical activity typically results in rupture of the mucosal seal and recurrence of PLF symptoms. The more often this sequence is repeated, the more likely that complications will develop.
A critical aspect of bed rest treatment is the patient's psychosocial support system. Patients cannot complete the demanding regimen of strict bed rest without a great deal of external assistance. Before beginning this treatment, we counsel the patients and their family, making sure that they understand and are fully able and ready to commit to a lengthy and treatment plan, with a proper support network.
Maximum healing occurs within 12 months of closure; if characteristic of connective tissue in other sites, the PLF heals with approximately 80% of its original tensile strength. (Note that the round window membrane in the human is only 0.3 mm thick.77) After a successful course of PLFs with bed rest, patients are allowed to gradually and incrementally increase their activities through a progression of six stages.76 Activities that are likely to cause recurrence (e.g., airplane flight) are restricted for at least 1 year after PLF closure. Successfully treated PLF patients are instructed never to fly if they have an upper respiratory infection or if they have poor eustachian tube function (i.e., cannot clear their ears when exposed to altitude or barometric pressure changes).
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