Vestibular Test Battery Addendum (Calorics/Rotational/VEMP)

Patient Name: [Patient full name]

MRN: [Medical record number]

DOB: [Date of birth]

Encounter ID: [Encounter identifier]

Test Date(s): [Date(s) tests performed]

Addendum Date: [Date this addendum is authored]

Ordering Clinician: [Ordering clinician name and credentials]

Interpreting Clinician: [Interpreting clinician name and credentials]

Performing Technologist: [Name and credentials] (Only include if different from interpreter)

Parent Report Reference: [Parent vestibular evaluation report date and identifier] (If parent report not yet available, note "Parent report pending")

Scope

[Brief statement of addendum purpose summarizing advanced vestibular components documented] (Limit to 2–3 sentences)

Component Status: Calorics: [performed / attempted but incomplete / not performed]; Rotational Chair: [performed / attempted but incomplete / not performed]; cVEMP: [performed / attempted but incomplete / not performed]; oVEMP: [performed / attempted but incomplete / not performed]

[Explanation of incomplete testing and which data remain valid] (Only include if any component was attempted but incomplete)

Clinical Indication

Reason for Testing: [Primary indication from referral: vertigo, imbalance, suspected otolith disorder, post-operative evaluation, etc.]

• Relevant History: [Ear surgery, TM perforation, conductive hearing loss, cervical or visual limitations, recent illness, medication use affecting vestibular function] (Only include if relevant to interpretation)
• Pre-Test Instruction Adherence: [Caffeine/medications not withheld or other non-adherence] (Only include if non-adherence affects validity)
• Patient State: [Alertness and cooperation during testing]
• Adverse Reactions: [Nausea/emesis, vasovagal episode, ear discomfort, and disposition] (Only include if occurred)

Caloric Testing

(Only include this section if calorics were performed or attempted)

Technique/Parameters: [Recording method: VNG / ENG]; [Stimulus type: air / water]; [Temperatures: warm and cool in °C]; [Irrigation duration in seconds]; [Patient positioning]; [Irrigation sequence]; [Otoscopy findings: TM status, cerumen]; [Protocol modifications and rationale if applicable]; [Quality notes: goggle fit, eye tracking, artifact management if applicable]

Ear	Temperature	Peak SPV (°/s)	Response Quality
[Right / Left]	[Temperature °C]	[Peak SPV]	[valid / borderline / repeated]

(Include only rows for irrigations actually performed)

• Unilateral Weakness: [UW %] ([Right / Left] weaker)
• Directional Preponderance: [DP %] ([Right-beating / Left-beating])
• Fixation Suppression: [intact / impaired / not tested]
• Spontaneous Nystagmus: [present: direction, intensity °/s, condition tested / absent]

(If absolute SPV values are very low, include: "Absolute caloric responses are low; percent asymmetry metrics may be unreliable.")

Rotational Chair Testing

(Only include this section if rotational chair testing was performed or attempted)

Setup/Protocols: [Recording method]; [Environment: total darkness, IR video]; [Alerting task used]; [Protocols performed]; [SHA frequencies tested and peak chair velocity °/s]; [Velocity step magnitude and direction convention]; [Visual suppression target type]

Sinusoidal Harmonic Acceleration (SHA)

Frequency (Hz)	Gain	Phase (°)	Asymmetry (%)	Classification
[Frequency]	[Gain]	[Phase]	[Asymmetry]	[normal / abnormal]

(Include only rows for frequencies actually tested)

Velocity Step

Direction	Post-Rotary Gain	Time Constant (s)	Quality Note
[Rightward / Leftward]	[Gain]	[Time constant]	[valid / borderline / repeated / artifact]

(Include only rows for steps actually performed)

• Visual Suppression/Fixation Index: [Value] ([intact / impaired])
• Quality/Limitations: [Poor alertness at low frequencies, repeated runs, motion sickness, etc.] (Only include if applicable)

VEMP Testing

(Only include this section if cVEMP and/or oVEMP was performed or attempted)

Shared Stimulus Parameters: [Stimulus type: tone burst / click]; [Frequency if tone burst]; [Intensity with units]; [Stimulus rate]; [Averages per run]; [Transducer type]; [Response replication: yes / no]

General Limitations: [Conductive hearing loss, poor muscle activation, inability to maintain gaze, artifact] (Only include if factors limiting interpretability are present)

cVEMP

(Only include if cVEMP was performed or attempted)

Montage/Activation: [Electrode montage]; [SCM activation method]; [Activation adequacy: EMG monitoring/target range achieved]

Ear	Response	P13 Latency (ms)	N23 Latency (ms)	Amplitude	Threshold (dB)
[Right / Left]	[present / absent]	[P13 latency]	[N23 latency]	[Amplitude: raw / corrected]	[Threshold] (if measured)

(Include only rows for ears actually tested)

• Interaural Asymmetry Ratio: [Value %] (Method: [raw / corrected])
• [Explanation of absent response: likely physiologic vs technically limited] (Only include if response absent)

oVEMP

(Only include if oVEMP was performed or attempted)

Setup: [Electrode placement]; [Upgaze maintenance method and adequacy]

Stimulus Ear	Response	N10 Latency (ms)	P16 Latency (ms)	Amplitude	Threshold (dB)
[Right / Left]	[present / absent]	[N10 latency]	[P16 latency]	[Amplitude]	[Threshold] (if measured)

(Include only rows for ears actually tested)

• Interaural Asymmetry Ratio: [Value %]
• [Explanation of absent response: likely physiologic vs technically limited] (Only include if response absent)

Integrated Interpretation

• Calorics: [Unilateral weakness with side and %; directional preponderance; fixation suppression status; spontaneous nystagmus; reliability qualifier if absolute responses low]
• Rotational Chair: [Overall gain pattern, phase lead/lag, asymmetry across frequencies, time constants, visual suppression integrity]
• VEMP: [cVEMP/oVEMP presence/absence, asymmetry, thresholds, latency patterns, reliability qualifiers]

Physiologic Impression: [Pattern consistent with / Findings suggest] [Site-of-lesion characterization: peripheral unilateral vestibular hypofunction, bilateral vestibulopathy, utricular/saccular involvement, central ocular motor findings, etc.]

Limitations: [Factors qualifying interpretation: poor alertness, inadequate muscle activation, low absolute responses, technical artifact, incomplete data] (Only include if limitations present)

Recommendations

(Omit this section if no specific recommendations)

• [Correlation with audiometry and/or imaging]
• [Vestibular rehabilitation referral]
• [Repeat testing recommendation if results technically limited]
• [Follow-up with ordering clinician or specialty clinic]

Authentication

Interpreting Clinician: [Name, Credentials]

Signature: [Signature] Date/Time: [Date and time]

Report Status: [Preliminary interpretation pending final review / Final report]