Some people with fistulas find that their symptoms get worse with coughing, sneezing, or blowing their noses, as well as with exertion and activity. Here dizziness is associated with a difference in pressure between ears. This condition remains difficult to document. Head trauma is the most common cause of fistulas, usually involving a direct blow to the ear. Forceful coughing, sneezing or straining as in lifting a heavy object may rarely cause a fistula.
Some patients develop symptoms attributed to fistula following airplane decent.
Rarely the bone between the ear and brain area is missing or thin, causing symptoms very similar to that of a fistula. Pathologically, fistulae have been reported in parts of the bone of the otic capsule other than the canals or window areas. Their significance is controversial. Fistulas may occur in one or both ears, but bilateral fistulas are thought to be exceedingly rare. However, for the others, there is considerable controversy about how to make the diagnosis.