Working Diagnosis:
Bilateral Superior Semicircular Canal Dehiscence (SSCD)

Treatment:
She trialed 3 months of vestibular rehab, which improved her nausea experienced with driving, but did not improve her noise induced symptoms. Therefore, she underwent reconstruction of her superior semicircular canal dehiscence (SSCD) on the more affected side. Due to ongoing symptoms, she then had the contralateral side reconstructed as well.

Outcome:
After both surgeries, she had 70% improvement in her sound-induced symptoms. She was able to return to teaching music class and listen to other musicians. She continues to have difficulty conducting or playing in large ensembles but can play in her small quintet up to two hours at a time. She was able to continue running without difficulty.

Author's Comments:
- Dizziness is quite common after concussion though most cases resolve in the first 3 weeks. It is difficult to distinguish between vestibular and non-vestibular causes on physical exam alone, making it challenging to detect inner ear injuries after trauma to the head. In this patient, PSaSRC seemed less likely, given that symptoms were brought on only with noise, and not with exercise or cognitive challenge. Benign paroxysmal positional vertigo (BPPV) is the most common inner ear condition causing post-concussion dizziness but is induced by changes in position rather than noise, which was not seen in this patient. Other injuries to the inner ear may be a cause for refractory episodes of vertigo, such as SSCD or perilymphatic fistula (PLF), both of which can present with sound and/or pressure-induced vertigo. Temporal bone fractures typically present with less severe symptoms and presents with vertigo with head movements. CT temporal bone can confirm the diagnosis for a temporal bone fracture, SSCD, and PLF. Vestibular migraines may be seen after brain injury and present very similarly to inner ear injuries, but would have a normal workup with ENT and are treated with typical migraine management.

Tullio phenomenon is defined as sound-induced vertigo, nausea, or nystagmus, as was seen in this patient. SSCD can be addressed with vestibular therapy, though refractory cases require surgical correction. If a patient experiences post-concussive dizziness for longer than 3 months, or presents with either Tullio phenomenon, hearing loss, or hyperacusis, they should undergo additional workup to evaluate for other etiologies.

Editor's Comments:
Dizziness is the second most common symptom after concussion. The most common cause is BPPV which often resolves with vestibular therapy. If symptoms do not resolve within the first 3 months, it is important to get further imaging and evaluate for other possible less common causes such as SSCD.

References:
1) Gianoli G.J.(2021). Post-concussive Dizziness - A Review and Clinical Approach to the Patient, Frontiers in Neurology, 12, 718318

2) Kolev O.I., Sergeeva, M. Vestibular disorders following different types of head and neck trauma. Functional Neurology 31(2), 75-80

3) Weinreich H.M., Carey J.P. (2019). Perilymphatic Fistulas and Semi-Circular Canal Dehiscence Syndrome. (93-100).

4) Brodsky J.R., Shoshany T.N, Lipson S. Zhou G. (2018). Peripheral Vestibular Disorders in Children and Adolescents with Concussion. Otolaryngology-Head and Neck Surgery 159(2), 365-370

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