A method to arrive precisely at the diagnosis of perilymph fistula remains impossible. As in many inner ear conditions, we have been hampered by a lack of pathologic data because the condition is not lethal and so timely pathologic examination of the inner ear is impossible. This situation is not dissimilar to most inner ear disorders and forces the otolaryngologist to integrate and interpret all data (history, physical examination, and diagnostic tests) to position perilymph fistula high in the differential diagnosis for the condition. If the diagnosis of perilymph fistula is entertained, surgical exploration of the oval and round windows is the only way to confirm the diagnosis. Controversy abounds, even in this realm of intraoperative identification of a perilymph leak. Fluid in the oval or round window niches has been attributed to pooling of residual local anesthetics,9 and perilymph labeling, especially with fluorescein, has yielded mixed results.10 Moreover, the number of negative explorations associated with improvement of symptoms raises the question of the placebo effect versus closure of intermittent perilymph leaks that simply are not active at the time of surgical exploration.

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