Prioritizing Vestibular Laboratory Testing Based on Symptom Time Course: A Narrative Review

Background: Advances in vestibular diagnostic technology have expanded the range of laboratory investigations available for the evaluation of dizziness. However, comprehensive vestibular testing batteries often require specialized equipment, trained personnel, and significant testing time. In addition, some investigations such as caloric testing may provoke substantial patient discomfort. Performing the full range of vestibular tests in every patient presenting with dizziness may therefore be inefficient and unnecessary.

Methods: A narrative review of the literature was conducted to examine the diagnostic performance and clinical utility of commonly used vestibular investigations including the video head impulse test (vHIT), caloric testing, vestibular evoked myogenic potentials (VEMP), and rotatory chair testing. Evidence was synthesized to develop a pragmatic framework for prioritizing vestibular investigations according to the clinical time course and suspected etiology of dizziness.

Results: vHIT provides rapid assessment of high-frequency vestibulo-ocular reflex function and is particularly useful as a first-line investigation in acute and subacute unilateral vestibular disorders. Rotatory chair testing may provide additional insight into vestibular compensation and global vestibular function, particularly in chronic or bilateral vestibular disorders. Vestibular evoked myogenic potentials demonstrate high specificity for assessing otolith pathway integrity and may be useful in targeted diagnostic scenarios such as hydropic ear disease, isolated otolith dysfunction, or superior semicircular canal dehiscence. Caloric testing evaluates low-frequency horizontal semicircular canal function and remains valuable in selected conditions such as Ménière’s disease or unilateral vestibular hypofunction.

Conclusion: A syndrome-based approach to vestibular laboratory testing may allow clinicians to select investigations more judiciously according to the clinical time course of dizziness. Implementing a decision-tree framework for vestibular test prioritization may improve diagnostic efficiency, reduce unnecessary testing, and support scalable models of vestibular diagnostic care.