The audiogram is similar to what was shown from several years prior; the loss remains conductive with a masking dilemma.  Tympanograms are normal; acoustic reflexes are absent bilaterally.

• Does absent reflexes support your tentative diagnosis or make it less probable?

Vertebral artery screen was negative.

Stepping Fakuda showed turn left

Sensory Organization Tests results:

Standing eyes open – no sway

Standing eyes closed – sway

Step forward eyes open – no sway

Step forward eyes closed – sway

Standing on foam eyes open – no sway

Standing on foam eyes closed – fall

• Interpret this pattern.

VEMP P13-N23 latencies were normal; VEMPs were present bilaterally down to low stimulus levels (e.g. 65 dBnHL)

Oculomotor tests are normal.

There was no gaze nystagmus.

Headshake nystagmus – negative

Hallpike negative.

Positional testing did not provoke nystagmus.

Perilymphatic fistula test was positive – low intensity right beating nystagmus and dizziness occurred with both positive and negative pressure to the right external canal.  Testing was negative left ear.

• Does this mean that the physician who said there was a perilymphatic fistula is correct?

The patient was asked to vocalize and gaze testing was re-evaluated. It showed oblique right/upward beating nystagmus and the patient experienced dizziness.

• What is that phenomenon called?  What lesion does it suggest?