Fluorescein as an easy, low-cost, indirect, or reverse intraoperative marker to rule out perilymph versus local injection.

Clear fluid found in the dependent portions of the middle ear (round and oval windows) is generally assumed to be perilymph (PL). However, all clear fluid observed at middle ear exploration is not necessarily PL. PL should be distinguished from local injection. An accumulation of the local injection could be confused with perilymph, causing the surgeon to make an inaccurate perilymph fistula (PLF) diagnosis. There is no standard way of distinguishing perilymph from local injection, as both are clear, watery fluids. Fluorescein, tagged with a mixture of xylocaine and epinephrine (FLOTAX) was used as the local injection in 10 patients undergoing middle ear exploration for possible PLF. FLOTAX was injected into the vascular strip and ear canal skin in routine fashion. Transtympanic endoscopy and special Zeiss custom fluorescein filters were used to document any accumulation of fluid in the dependent portions of the middle ear and confirm whether any fluorescein (from the FLOTAX) was present. The middle ear was checked both before (endoscopically) and after raising the tympanomeatal flap. After the local injection, FLOTAX was observed to accumulate in dependent portions of the middle ear before raising the tympanomeatal flap in six of 10 ears. In the other four ears, FLOTAX slowly seeped into the middle ear cleft after the tympanomeatal flap was elevated and manipulated. Fluorescein can be used as an inexpensive, indirect intraoperative marker or reverse test for possible PLF. By eliminating a likely and common offender (local injection), any accumulation or reaccumulation of clear fluid that is not fluorescein tagged may more confidently be identified as possibly perilymph. The use of FLOTAX helps eliminate the confusion between the local injection and potential PLF. It does not in any way eliminate the possibility of other transudates from incisions, allergic reactions, or other manipulation of the tympanomeatal flap or middle ear mucosa.