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The Role of Surgery in Vestibular Care
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For many people living with a vestibular disorder, treatment focuses on medications, vestibular rehabilitation, and lifestyle changes. But in some cases, surgery may be considered when symptoms are severe, persistent, or caused by a structural problem that cannot be addressed in other ways.
The decision to undergo surgery is rarely simple. Patients and healthcare providers must carefully weigh the potential benefits against the risks, consider alternative treatments, and prepare for what can sometimes be a challenging recovery process. While surgery can be life-changing for the right candidate, it often comes with its own physical and emotional hurdles.
In today’s episode, we’ll explore how doctors determine when an operation is appropriate, what patients can realistically expect before and after surgery, and how recovery unfolds over time.
Guests
Stefanie Adams suffered multiple traumatic brain injuries and had her third concussion in 2017. As soon as she hit her head, she felt off-balance and started to sway. Over the next year, she developed terrible migraines and dizziness. Eventually the migraines left, but the dizziness stayed. A year later, she discovered that she had a perilymph fistula (a hole in the membrane separating the middle and inner ears) when she got the flu, blew her nose, and the room started to spin. She’s had surgery to repair the fistula and is now a VeDA Ambassador, Board Member, and vestibular advocate.
Habib G. Rizk, M.D. grew up in Beirut, Lebanon. He attended the Faculty of Medicine-Saint Joseph University in Beirut, Lebanon, and pursued an Otolaryngology — Head & Neck Surgery residency at Hôtel-Dieu de France Hospital in Beirut, followed by an Otologic Medicine and Surgery Fellowship under the mentorship of Dr. Michael Teixido at Christiana Care in Wilmington, Delaware, and a two-year Neurotology fellowship at the Medical University of South Carolina. Dr. Rizk’s interests span all areas of otology and neurotology, with a specific focus on the medical and surgical management of vestibular disorders. He is a professor in the MUSC Department of Otolaryngology, Head & Neck Surgery, and the Director of the Multidisciplinary Vestibular Program. Dr. Rizk is currently on the board of directors and past president of the Vestibular Disorders Association. He is a member of the Bárány Society and a fellow of the American Neurotology Society and the American Otological Society. He is also a member of the American Balance Society and of the Otology and Neurotology Education Committee of the American Academy of Otolaryngology-Head and Neck Surgery.
When Surgery Becomes Part of the Vestibular Journey
For most people living with a vestibular disorder, treatment never involves an operating room. Medications, vestibular rehabilitation, lifestyle changes, and careful symptom management are the mainstays of care. But for a small subset of patients, surgery enters the picture—not as a quick fix, but as a carefully weighed option when life has been narrowed by unrelenting dizziness, vertigo, and imbalance.
In this ICU Podcast episode, vestibular patient and advocate Stefanie Adams and neurotologist Dr. Habib Rizk explore what it really means to consider—and live through—vestibular surgery. Their perspectives together paint a nuanced picture: surgery can be life-changing, but it is rarely simple, never guaranteed, and always embedded in a larger story of diagnosis, recovery, and emotional resilience.
Stefanie’s Story: From BedBound to Reclaiming Her Life
Seven years out from her surgery, Stefanie can clearly see the “before” and “after” lines in her life.
Life Before Surgery: “Pretty Bleak”
Stefanie’s journey began with multiple traumatic brain injuries and a third concussion in 2017. Almost immediately afterward, she felt off balance. She started to sway. Over the next year, severe migraines and dizziness took over her life. Eventually, the migraines faded—but the dizziness did not.
Her symptoms were devastating:
- Bedbound and unable to walk or move without feeling like the world was spinning
- Fainting in the hallways at work, unable to sit at her desk or focus
- Forced to take medical leave, desperate to figure out what was wrong
- Social life shrinking as she couldn’t drive, use public transportation, or meet friends outside the house
- Total dependence on others—her boyfriend driving her to appointments, family and friends coming to her because she couldn’t go to them
She describes a particularly disturbing symptom: her eyes would “torque” all the time. At the time, she had no idea this was a key sign of her underlying problem. Meanwhile, every part of her life—work, friendships, and her intimate relationship—was fraying under the strain of constant illness. As an independent, oldest daughter used to taking care of herself, needing constant support was emotionally crushing.
After months of research from her bed, Stefanie sent what she describes as a “whim” email to a surgeon, explaining that she suspected she had a perilymphatic fistula—a hole in the membrane separating the middle and inner ear. Around that time, a bout of the flu and a seemingly simple act of blowing her nose triggered intense room-spinning vertigo. Within two months of being evaluated, she was in surgery. The date—July 25, 2019—has become a personal anniversary marking the turning point in her life.
Choosing Surgery Despite Fear
Stefanie is candid: surgery is one of her biggest fears. For her family, the fact that she wanted surgery “tomorrow” was a sign of just how sick she was.
Her surgeon estimated about a 50% chance that the operation would give her meaningful relief. For someone whose world had shrunk to a bed and a wedge pillow, that was enough.
She was willing to accept risk— including the possibility of hearing loss—because the alternative was continuing a life that no longer felt like her own. She emphasizes that she knows patients who had the same surgery for perilymphatic fistula and did not experience the same degree of improvement. That contrast makes her especially aware of how fortunate she is and how individualized outcomes can be.
Recovery: Caution, Anxiety, and Small Milestones
After surgery, Stefanie woke up and felt something was different. The intense, constant vertigo that had dominated her life began to recede. But recovery was not instantaneous—and it wasn’t just physical.
Because perilymphatic fistula repair comes with strict post-op precautions (no heavy lifting, moving carefully, avoiding strain), and because she was terrified of “messing up” the repair, Stefanie spent the first few months mostly lying flat, watching TV on an iPad, and moving only with support. She describes:
- Mild vertigo immediately after waking up, likely from how her head was positioned, that improved over the first day
- Gradual improvement week by week, rather than a single “miracle moment”
- Ongoing anxiety—texting her surgeon about every new sensation (“My jaw made a noise—did I ruin the surgery?”)
As the surgical packing dissolved, she began to notice her hearing improving. She returned to work and realized her eyes no longer rolled back when she tried to use a computer. Her neuro-ophthalmologist confirmed that a binocular vision issue that had required special glasses had resolved after surgery. She could now work at a desk from 9 to 5 without her visual system breaking down.
The milestones that followed were both ordinary and profound:
- Walking down hallways without fearing she would faint
- Lying on her side again and cuddling with her partner without triggering spinning vertigo—an emotional moment that left them both in tears
- Flying, after years of refusing to get on a plane
- Driving again, which took her several years to feel ready for due to lingering anxiety
- Working out, lifting, traveling independently, and commuting to the office multiple times a week
Today, seven years after surgery, Stefanie reports that her vertigo and dizziness have subsided, and she is able to live a full, active life. She’s honest that fear slowed her from returning to some activities sooner—but she’s equally clear that the slow, cautious path was worth it for her peace of mind.
Dr. Rizk’s Perspective: When Is Surgery the Right Choice?
While Stefanie’s experience shows what’s possible when surgery is the right fit, Dr. Habib Rizk emphasizes that most vestibular disorders are not treated surgically—and even when surgery is an option, it is rarely urgent and never one-size-fits-all.
Conditions Where Surgery Is Rare
For many vestibular conditions, surgery either plays no role or is reserved for only the most extreme, treatment-resistant cases:
- Meniere’s disease
- Dr. Rizk estimates that fewer than 5% of patients will ever need surgery in their lifetime.
- He may perform one or two labyrinthectomies every couple of years despite seeing around 100 new Meniere’s patients each year.
- Many patients improve over time as the disease “burns out,” or respond to conservative measures, especially since clinicians have recognized a strong link between Meniere’s and migraine. Migraine medications are now a common part of Meniere’s treatment, even in patients without classic migraine.
- Vestibular migraine
- This is a medically managed condition.
- There is no role for vestibular surgery, although some patients may receive nerve blocks or Botox for severe headache burden.
Conditions Where Surgery May Be Appropriate
In some diagnoses, surgery is a central option—but still only for the right patients under the right circumstances.
- Superior Semicircular Canal Dehiscence (SSCD)
- This is a “third window” disorder caused by a hole in the bony structure over the superior semicircular canal.
- Surgery (often via craniotomy to plug the canal) is the definitive treatment when symptoms are truly debilitating.
- Yet, out of 100 SSCD patients, fewer than 10% proceed to surgery. Many have mild symptoms that can be observed over time.
- Even though SSCD is benign and not life-threatening, surgery carries risks: hearing loss, imbalance, prolonged recovery, and the demands of a craniotomy.
- Perilymphatic fistula
- A rare condition—Dr. Rizk estimates he has seen about five clear-cut cases in ten years, and he operated on those.
- Sometimes there is a clear inciting event: trauma to the ear canal, forceful nose blowing, or—as in Stefanie’s case—prior concussions setting the stage.
- Treatment options include bed rest, blood patch, and ultimately surgical round and oval window plugging.
- Compared with craniotomy for SSCD, this operation carries a lower risk and generally does not require opening the skull, which can make the risk–benefit profile more favorable when symptoms are severe.
- Not all perilymphatic fistulas are obvious. “Spontaneous” cases may be controversial and can mimic other conditions, such as sudden hearing loss or labyrinthitis. In those scenarios, clinicians must proceed slowly—ruling out other causes, trying conservative treatments, and only moving to surgery when the evidence is compelling.
- Vestibular schwannoma (acoustic neuroma)
- This is a benign tumor of the vestibular nerve. Interestingly, most patients present with hearing loss rather than dizziness, despite the tumor arising from the balance nerve.
- The default approach is often watchful waiting: monitoring tumor growth and hearing over time. This can improve quality of life by allowing patients to process the diagnosis and make informed decisions.
- Surgery or radiation may be considered if the tumor grows, threatens nearby brain structures, or if hearing is already significantly compromised.
- Most surgical approaches, especially the translabyrinthine route, result in hearing loss on the affected side and cause acute vertigo due to sudden loss of vestibular input. With therapy, most people can compensate and return to normal activities.
Misconceptions and the Importance of Counseling
Dr. Rizk highlights several common misconceptions:
- “There’s a hole—just fix it.”
Patients with SSCD sometimes arrive convinced that the dehiscence seen on a CT scan is the sole cause of all their symptoms. In reality, many people have radiologic dehiscence without matching symptoms. Fixing the “hole” won’t fix a problem that isn’t actually coming from that structure. - Overlapping conditions
Vestibular disorders often co-exist—migraine, concussion, third window syndromes, anxiety, and more. Surgery may only address one piece of a complex puzzle. If expectations aren’t realistic, patients can feel they’ve traded one problem for another, especially if they experience side effects like hearing loss. - Recovery is purely physical
Dr. Rizk underscores that anxiety can sometimes impact quality of life more than the vestibular disorder itself. Fear of driving, flying, or moving freely may persist even when the inner ear is reasonably stable. Surgery cannot fix anxiety; it has to be addressed alongside medical and surgical care.
Clear, honest counseling is therefore critical. Surgeons must help patients understand:
- What symptoms surgery is likely to improve
- What risks it carries, including the possibility of persistent dizziness or hearing loss
- How long recovery might realistically take
- When not to operate, even if imaging shows something that looks “fixable”
For those who do pursue surgery, like Stefanie, a trusting relationship and realistic expectations can make the difference between feeling betrayed by the outcome and, even in the face of side effects, feeling that they made the right choice.
Surgery as One Chapter, Not the Whole Story
Taken together, Stefanie’s lived experience and Dr. Rizk’s clinical insight remind us that vestibular surgery is neither a miracle cure nor a last resort to be avoided at all costs. It is a tool—sometimes powerful, sometimes inappropriate, always complex.
For a small number of patients with specific structural problems and debilitating symptoms, surgery can be the bridge back to a life of movement, work, connection, and joy. For many others, the best care will never involve an operating room at all.
What remains constant across these paths is the need for:
- Thoughtful, individualized assessment
- Honest, detailed communication about risks and benefits
- Attention to the emotional toll of chronic dizziness
- Space for patients, like Stefanie, to move at their own pace through fear, recovery, and ultimately, renewed possibility
