Vestibular Evaluation Report (ENG/VNG)

Patient: [Name], [DOB], [MRN]

Encounter: [Date], [Location]

Ordering Clinician: [Name, credentials, referring service]

Rendering Clinician: [Name, credentials] (If interpretation performed by a different clinician, specify interpreter name and credentials)

Reason for Test: [One-line referral question/problem statement]

History / Symptom Profile

Chief Complaint: [Patient-stated primary concern] (Include a brief direct quote if it clarifies symptom type)

Symptom Chronology & Characteristics: [Onset], [time course/progression], [episode frequency], [episode duration], [triggers: positional change / head movement / visual motion / exertion / other], [symptom type: spinning vertigo / non-spinning dizziness / imbalance / oscillopsia], [severity], [functional impact]

• Associated Otologic Symptoms: [Hearing change], [tinnitus], [aural fullness] (Include laterality if known)
• Neurologic Red Flags: [New focal deficits / severe headache / diplopia / syncope / none] (If present, note urgency or actions taken)
• Falls History: [Falls in past 12 months], [injury yes/no], [assistive device use]
• Prior Vestibular Workup/Treatments: [Prior testing], [imaging], [therapies/vestibular rehab], [repositioning maneuvers], [response]
• Relevant Medical History: [Migraine], [peripheral neuropathy], [vision impairment], [cardiovascular disease], [cervical spine issues], [other relevant conditions]
• Medications Affecting Vestibular/CNS Function: [Vestibular suppressants, sedatives, antihistamines, benzodiazepines, alcohol], [timing relative to test] (If medications were not held per pre-test instructions, explicitly note and flag for cautious interpretation)

Pre-Test Screening

• Medication Restriction Adherence: [Adherent / Not adherent / Partial] (List specific agents taken within restriction window if applicable)
• Caloric Contraindications: [Cardiovascular instability / recent ear surgery / TM perforation / cerumen occlusion / active otitis externa or media / none identified]
• Positional Testing Precautions: [Cervical ROM limitations / orthostatic intolerance / mobility restrictions / back or hip precautions / none] (Describe any required modifications)
• Otoscopy: Right ear: [Normal / Abnormal: describe] | Left ear: [Normal / Abnormal: describe]
• Visual/Ocular Factors Affecting Recording: [Visual acuity], [strabismus], [baseline nystagmus], [inability to fixate], [corrective lenses in place] (Note impacts on calibration or fixation if applicable)
• Procedure Explanation & Tolerance: [Procedure explained and consent obtained]. Tolerance: [Good / nausea / required breaks / premature termination] (Document any adverse symptoms or reasons for early stop)

Methods

Recording: [VNG / ENG], [monocular / binocular]. Calibration: [Performed / not performed]. Fixation conditions: [How fixation was allowed and removed]. Alerting during calorics: [Method used]. Normative limits: [Lab-specific / manufacturer norms], [age-adjusted: yes/no].

Protocol Deviations: [None / describe deviations such as goggle repositioning, modified positions, incomplete irrigations, equipment issues] (If deviation affects specific test outcomes, note the impacted measures)

Test Battery

(Status: Performed / Not Performed / Attempted Incomplete. Include reason if not completed.)

• Oculomotor Screening
  • Spontaneous nystagmus (with/without fixation): [Status]
  • Gaze-evoked nystagmus: [Status]
  • Smooth pursuit: [Status]
  • Saccades: [Status]
  • Optokinetic nystagmus (OKN): [Status]
• Positional/Positioning
  • Static positional testing: [Status]
  • Dix-Hallpike Right: [Status]
  • Dix-Hallpike Left: [Status]
  • Supine roll test Right: [Status]
  • Supine roll test Left: [Status]
• Head-Shake Test: [Status]
• Caloric Testing: [Bithermal / Monothermal], [Water / Air]. Irrigations completed: [WR / WL / CR / CL]. Status: [Status]

Results

Data Quality & Interpretability: [Good / Fair / Poor]. [Artifact issues], [alertness], [fixation problems], [calibration reliability]. (If quality limits interpretability, state explicitly)

Oculomotor Testing

• Spontaneous Nystagmus: With fixation: [Present / Absent]; Without fixation: [Present / Absent]. Direction: [Right-beating / Left-beating / Vertical / Torsional / Mixed]. Intensity: [SPV deg/s]. Effect of fixation: [Suppressed / Not suppressed / Not tested].
• Gaze-Evoked Nystagmus: Positions tested: [Primary / Right / Left / Up / Down]. Direction pattern: [Describe]. Intensity: [SPV deg/s].
• Smooth Pursuit: [Gain], [asymmetry], [qualitative: normal / impaired / saccadic / age-consistent].
• Saccades: Latency: [Normal / Prolonged]. Velocity: [Normal / Reduced]. Accuracy: [Hypometric / Hypermetric / Normal]. Notable features: [Intrusions / dysmetria / none].
• OKN: [Symmetric / Asymmetric], [gain values if available], [qualitative description].

Positional/Positioning Testing

• Static Positional Testing: Positions tested: [Supine / Head right / Head left / Head center / 30° head elevation / Other]. Nystagmus: [Direction], [Persistent / Transient], [SPV deg/s]. Fixation suppression: [Present / Absent]. Associated symptoms: [Reported / Not reported].
• Dix-Hallpike Right: Method: [Standard / Modified]. Latency: [sec]. Duration: [sec]. Nystagmus pattern: [Direction including torsional component]. Fatigability: [Yes / No]. Reversal on sitting: [Yes / No]. Subjective vertigo: [Present / Absent].
• Dix-Hallpike Left: Method: [Standard / Modified]. Latency: [sec]. Duration: [sec]. Nystagmus pattern: [Direction including torsional component]. Fatigability: [Yes / No]. Reversal on sitting: [Yes / No]. Subjective vertigo: [Present / Absent].
• Supine Roll Test Right: Latency: [sec]. Duration: [sec]. Nystagmus pattern: [Geotropic / Apogeotropic], intensity vs contralateral: [Greater / Lesser / Similar]. Symptoms: [Present / Absent].
• Supine Roll Test Left: Latency: [sec]. Duration: [sec]. Nystagmus pattern: [Geotropic / Apogeotropic], intensity vs contralateral: [Greater / Lesser / Similar]. Symptoms: [Present / Absent].

Head-Shake Test

Method: [Frequency, duration, eyes closed/open]. Post-head-shake nystagmus: [Direction], duration: [sec], intensity: [SPV deg/s]. Symptom provocation: [Reported / Not reported].

Caloric Testing

Parameters: [Water / Air], temperatures: [Warm °C / Cool °C], duration per irrigation: [sec], patient position: [Supine with 30° head elevation / Other], alerting: [Yes / No].

SPV per Irrigation: Warm Right (WR): [deg/s] | Warm Left (WL): [deg/s] | Cool Right (CR): [deg/s] | Cool Left (CL): [deg/s]

Asymmetry Metrics: Canal paresis/unilateral weakness: [%], weaker ear: [Right / Left]. Directional preponderance: [%], direction: [Right-beating / Left-beating].

Fixation Suppression: [Normal / Impaired / Not tested].

Total Response Strength (Sum SPV): [deg/s] (Note if values suggest bilateral reduction based on lab thresholds)

Limitations: [None / If responses are very small, note that asymmetry calculations may be unreliable / incomplete irrigations / artifacts affecting interpretation]

Clinical Impression

Summary Interpretation: [No evidence of / Findings consistent with / Findings suggestive of] [peripheral unilateral vestibular hypofunction (specify side) / bilateral vestibular hypofunction / benign paroxysmal positional vertigo (specify canal) / central ocular-motor involvement / mixed / indeterminate / normal vestibular function].

• Supporting Objective Findings: [Key results supporting interpretation, e.g., caloric asymmetry, positional nystagmus characteristics, central ocular-motor signs]
• Confidence & Limitations: [High / Moderate / Limited] confidence due to [missing tests / poor data quality / medication non-adherence / incomplete battery / protocol deviations / none]. (If a critical component was not performed, include a one-sentence limitation statement)
• Differential Considerations: [Brief differentials if findings are non-specific] (Omit if diagnosis is clear)

Recommendations

1. Medical Referral: [ENT/Otology / Neurology / Neuro-otology / None indicated] for [reason], timeframe: [Urgent / Soon / Routine].
2. Vestibular Rehabilitation: [Indicated / Consider / Not indicated] for [unilateral or bilateral hypofunction / persistent imbalance / deconditioning]. [Refer to vestibular PT / Provide home program].
3. Fall-Risk Mitigation: [Home safety counseling / assistive device evaluation / medication review / vision optimization / not indicated].
4. Further Diagnostic Testing: [vHIT / VEMP / Rotary chair / Audiologic evaluation / Imaging / None] (Include only if results would change management; specify rationale)
5. Patient Instructions: [Post-test precautions], [when to contact clinician or seek urgent care], [follow-up plan and timing].

(Use "Not assessed" if information was not obtained, "Unknown" if asked but patient unsure, "Not performed" with reason for tests not completed. Ensure all conclusions are supported by documented objective values.)

Clinician Signature: [Name, Credentials]

Date/Time: [Date, Time]