Case from the Aerospace Medicine Resident's Teaching File 30: A difficult differentiation between idiopathic perilymph fistula and psychosomatic dizziness and unsteadiness is addressed in the clinical presentation of an Army aviator, who presents with break-off phenomenon, chronic fatigue, and positional vertigo at the end of military flying career as a 'high time' pilot. A 40-year-old male Army aviator, assigned as the senior instructor pilot for an active duty Army aeromedical evacuation platoon, presents to you complaining of an anxiety provoking inflight incident that he has never experienced before. He is a master aviator with over 6,000 h of rotary-wing flying time. After transporting a patient to a nearby teaching hospital, he made the decision to return at a flight level of 9,000 ft to avoid hot, turbulent afternoon air currents. He was flying south into the sun and noted the usual brown haze on the horizon. He states that while not at the controls from the right seat of the UH-1H helicopter, he was looking at the Earth below through the chin bubble beneath his feet.


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