Introduction Perilymphatic fistula (PLF) is a difficult inner ear condition which is characterized as abnormal connection between inner and middle ear and subsequent leakage of inner ear liquid (perilymph) into the middle ear. The primary manifestations of PLF are sudden or progressive fluctuations, sensorineural hearing loss or deafness and/or vestibular symptoms ranging from dizziness to rotary vertigo. We present a case of a perilymphatic fistula secondary from traumatic injury to ear presenting as conductive hearing loss conservatively managed. Case discussion A 60 year old female sustained a left tympanic membrane perforation following a mechanical fall whilst using a cotton-tip applicator.She presented with acute vertigo, imbalance and conductive hearing loss in the affected ear. Clinical examination revealed profound vertigo on rightward head movement and a large anterior tympanic membrane 50% perforation. Audiometric evaluation demonstrated moderate to profound conductive hearing loss with an underlying mild-high frequency sensorineural component. CT of temporal bones revealed a small gas locule within the left ampulla of the superior semicircular canal. The patient was managed conservatively with vestibular rehabilitation, corticosteroids and anti-vertiginous therapy. Over the subsequent follow-up, vestibular symptoms improved significantly, though residual conductive hearing loss and tinnitus persisted. Conclusion In this case, the coexistence of tympanic membrane perforation and conductive hearing loss initially suggested a middle ear pathology; however radiological presence of a perilymphatic air and mild sensorineural hearing loss on high frequencies raised suspicion of injury to labyrinths. This case underscores the importance of integrating audiovestibular testing. Although intraoperative identification of perilymph leakage remains the diagnostic gold standard, clinical judgment and noninvasive investigations play pivotal roles in guiding management and follow-up.