Although lightning injuries are common, neuro-otologic sequelae are infrequently reported. The most common otologic injury encountered in the lightning strike victim is tympanic membrane rupture; the most common vestibular disturbance documented is transient vertigo. A variety of other clinical findings have been described in this population of patients. They include sensorineural hearing loss, conductive deafness, tinnitus, basilar skull fracture, avulsion of the mastoid bone, burns to the external auditory canal, and peripheral facial nerve palsy. The initial treatment of the lightning strike victim consists of basic life support measures. Once stabilized, the patient should undergo a complete otologic and vestibular evaluation. The majority of otolaryngologic problems encountered can be managed expectantly, with periodic re-evaluation. Tympanoplasty should be delayed for 6 to 12 months because of the frequent delay in spontaneous healing.