Enlarged Vestibular Aqueduct (EVA)
This information is intended as a general introduction to this topic. As each person is affected differently by balance and dizziness problems, speak with your health care professional for individual advice.
What is enlarged vestibular aqueduct?
The vestibular aqueduct (ves-TIB-you-lar AC-wa-duct) is a narrow tube that runs from the inner ear to deep in the skull. It contains the endolymphatic (EN-doe-lim-FAT-ick) duct, which connects the inner ear to a structure called the endolymphatic sac. Endolymph is the fluid in the inner ear.
Enlarged vestibular aqueduct1
Normally, the vestibular aqueduct is very narrow: halfway along its length, it is less than 1 millimeter (mm) across—about the width of a pin. But some people have a wider vestibular aqueduct, measuring 1.5 mm to 8 mm across. This is known as enlarged vestibular aqueduct (EVA).
People with EVA often have sensorineural hearing loss, with or without vertigo and balance problems. These problems often start in childhood; between 5% and 15% of children with sensorineural hearing loss have EVA. These problems are more common in girls than in boys, and they are more often found on both sides (bilaterally) than on one side. Typically, the person’s hearing gradually gets worse over time.
What causes EVA?
EVA seems to happen before birth, while the fetus is developing. The enlarged aqueduct does not seem to cause hearing loss. Instead, researchers believe that both EVA and hearing loss are caused by an underlying genetic problem.
Many people with EVA and hearing loss also have other structural changes in the inner ear. For example, EVA is most commonly associated with incomplete partition type 2 (also called the Mondini malformation). This abnormality consists of:
- cochlea (part of the inner ear that looks like a snail) with only 1.5 turns instead of the usual 2.5
- enlarged vestibule with normal semicircular canals
- enlarged vestibular aqueduct containing a dilated (wider) endolymphatic sac
EVA sometimes happens alone and sometimes with other disorders. For example, about 1 in 4 people with EVA and hearing loss have Pendred syndrome, which also causes thyroid problems. Mutations in a gene called SLC26A4 can cause EVA and Pendred syndrome. But not everyone with EVA has these mutations. We are still learning about other things that can cause EVA.
Other conditions that sometimes happen with EVA include:
- CHARGE syndrome
- distal renal tubular acidosis
- Waardenburg syndrome
- X-linked congenital mixed deafness
- branchio-oto-renal (BOR) syndrome
- oto-facial-cervical syndrome
Symptoms of EVA
Hearing symptoms of EVA may include:
- sensorineural hearing loss, such as trouble distinguishing words or a child not responding when their name is called
- for children, speech and language delays
Balance symptoms of EVA may include:
- episodes of vertigo that vary in length
- balance problems
- for children, delays in crawling or walking
Sometimes, the symptoms are first noticed or get worse after a head injury.
How EVA is diagnosed
EVA is most often diagnosed in young people, from toddlers to people in their 20s. This section assumes that you are a parent who is concerned about your child’s symptoms.
The doctor will ask about your child’s symptoms. Try to be as specific as possible about the symptoms and when they get better or worse.
The doctor will also ask about your child’s medical history, including any medications they are taking or recently stopped taking and any conditions they have been diagnosed with in the past. The doctor will also do a thorough physical and neurological exam.
Your child will probably have some of the following diagnostic tests:
- hearing and vestibular function tests
- an imaging test such as magnetic resonance imaging (MRI) or computed tomography (CT); these tests can show if the vestibular aqueduct is larger than usual and if there are any other abnormalities in the temporal bone
Treatment and management of EVA
So far, there is no treatment to reduce or slow hearing loss in people with EVA. It is important to identify hearing loss as early as possible, so that children and their caregivers can develop skills to help with communication. These skills may include sign language and cued speech, which uses hand signals and other visual signs to make the “building blocks” of speech (phonemes) visible.
You or your child will need regular follow-up care to monitor hearing and see if there have been any changes. This is especially important for very young children, who may not be able to tell you if something is wrong. Hearing aids will be recommended when there is significant hearing loss.
Surgery to drain excess fluid or remove the enlarged endolymphatic duct and sac is not helpful. It often causes severe hearing loss.
Some people with hearing loss and EVA may lose hearing gradually to a degree where hearing aids are no longer helpful. They may become candidates for cochlear implants. Surgery for cochlear implants does carry some risk. People with EVA are more likely to have serious leakage of cerebrospinal fluid (CSF) during surgery. CSF is the fluid that surrounds the brain and spinal cord. It is important to consider the risks and benefits of surgery carefully and discuss them with the surgeon.
About 1 in 3 people with EVA have sudden hearing loss after a minor head injury or barotrauma (sudden, extreme change in air pressure). For this reason, people with EVA are often told to try to protect their hearing by:
- avoiding contact sports
- wearing head protection for activities like bike riding or skiing
- avoiding loud noises
- avoiding situations that cause extreme, fast changes in air pressure, such as scuba diving
- avoiding playing wind instruments
- taking decongestants when flying if they have sinus or nasal congestion
What to expect in the future
In many people with EVA, hearing changes a lot or suddenly gets worse. It is not possible to predict who will have these sudden changes, so regular monitoring is important.
Researchers are studying the factors that cause EVA and hearing loss. In the future, we may know more about what causes them and how to prevent them.
- NIH Medical Arts (Accessed January 2, 2021)
Aimoni C, Ciorba A, Cerritelli L, Ceruti S, Skarżyński PH, Hatzopoulos S. 2017. Enlarged vestibular aqueduct: Audiological and genetical features in children and adolescents. Int. J. Pediatr. Otorhinolaryngol. 101, 254–258. Available from: https://bit.ly/2LleXxO
Hain TC. 2019. Enlarged vestibular aqueduct [WWW Document]. Dizziness--Balanc. Available from: https://bit.ly/3hCC4QC (accessed 7.24.20)
Honda K, Kim SH, Kelly MC, Burns JC, Constance L, Li X, Zhou F, Hoa M, Kelley MW, Wangemann P, Morell RJ, Griffith AJ. 2017. Molecular architecture underlying fluid absorption by the developing inner ear. eLife 6, e26851. Available from: https://elifesciences.org/articles/26851
National Cued Speech Association, 1995. Cued Speech Definition [WWW Document]. Natl. Cued Speech Assoc. Available from: https://bit.ly/2Mr8P7T (accessed 7.30.20).
National Institute on Deafness and Other Communication Disorders (NIDCD), 2017. Enlarged Vestibular Aqueducts and Childhood Hearing Loss [WWW Document]. NIDCD. Available from: https://bit.ly/3hFnJ61 (accessed 7.24.20).
Sennaroglu L, Saatci I. A new classification for cochleovestibular malformations. Laryngoscope. 03 Feb 2009. Abstract available from: https://bit.ly/3hEwzB5
Wolf, J., 2015. Advanced Management of Complex Cases: Enlarged Vestibular Aqueduct Jennifer Wolf [WWW Document]. AudiologyOnline. Available from: https://bit.ly/3n6wCGN (accessed 7.24.20).
Zalewski, C.K., Chien, W.W., King, K.A., Muskett, J.A., Baron, R.E., Butman, J.A., Griffith, A.J., Brewer, C.C., 2015. Vestibular Dysfunction in Patients with Enlarged Vestibular Aqueduct. Otolaryngol.--Head Neck Surg. Off. J. Am. Acad. Otolaryngol.-Head Neck Surg. 153, 257–262. Available from: https://bit.ly/3pJgFYX
Page updated January, 2021.