Perilymph fistula can lead to permanent hearing loss and intense vertigo, typically caused by head trauma, labour/straining, blast injuries, barotrauma, or in rare cases, coughing and sneezing. Most commonly, it affects the lateral semicircular canal. This case highlights a rare cause, imaging findings, and management of a perilymph fistula resulting in dense hearing loss after inadvertent avulsion of their stapes footplate while using a cotton swab. Whilst cleaning his ear with a Q-tip, JS’s elbow was struck by an opening door, forcing the cotton swab deep into the external auditory canal, perforating the tympanic membrane posteroinferiorly. This caused immediate vertigo, deafness, and vomiting. CT petrous bone imaging demonstrated middle ear fluid and gas in the vestibule. Detailed PTB sequences reviewed with a radiologist revealed compression injury with avulsion and tilt of the stapes footplate into the vestibule. Audiometry confirmed a sensorineural total loss of the right ear. Management of perilymph fistulae remains controversial. Park et al. supports early surgical intervention for perilymphatic repair to potentially improve long-term hearing outcomes; however, this improvement is often marginal and carries risks of iatrogenic deafness. Geerse et al suggest that Intravenous corticosteroids have shown some success in preserving hearing, though no established guidelines or diagnostic criteria exist. Sarna et al. propose a treatment algorithm, but most recommendations are based on case series and case reports. JS was managed with bed rest, aperients, head elevation, and avoidance of activities that could increase intracranial pressure or straining. Gradual mobilization followed, and JS was discharged safely on a tapering steroid course. A large tympanic membrane perforation remained, with clinical images illustrating the traumatic trajectory and stapes footplate dislocation.