A patient-oriented approach to perilymph fistula. The subject of perilymph fistula is controversial in part because the preoperative diagnosis of perilymph fistula is difficult. Patients suffering auditory and vestibular symptoms secondary to perilymph fistula, therefore, present a dilemma to the practicing physician. In some instances, patients with auditory and vestibular symptoms in the absence of perilymph fistula will be subjected to middle ear exploration without benefit, while in other instances patients with auditory and vestibular symptoms secondary to perilymph fistula will be denied surgical treatment. Auditory and vestibular symptoms are a quality of life issue. Therefore, in an effort to provide care of the highest quality the patient must be actively involved in the decision process. Such involvement can be meaningful only after the patient is carefully counseled as to the pros and cons of surgery, as well as the alternatives. A prognostic paradigm based on the personal experience of one of us (W.L.M.) with perilymph fistula patients is described and is used in patient consultation in an effort to facilitate decision making. 