When performing a full vestibular test battery, there is a logical order of the testing. The arrangement of the test rooms is dictated by the order of the test battery typically used for the dizzy patient. Case history interview and audiometric evaluation should be performed first to assess 1) the health and integrity of the ear canal and tympanic membrane prior to caloric irrigation, 2) auditory sensitivity and symmetry, and 3) possible presence of retrocochlear pathology. Inspection for gaze and spontaneous nystagmus must take place before any other vestibular tests, because they will affect all other tests. The oculo-motor test battery is usually performed prior to positional or caloric testing because the task is similar to the calibration procedure and it is unlikely to provoke vegetative symptoms that may prevent completion of remaining scheduled tests.
Positional and positioning (Dix-Hallpike) testing should be performed before caloric irrigation, which could inadvertently provoke positional vertigo when placing the patient in the thirty-degree supine position. Additionally, a positive Dix-Hallpike and appropriate Canalith Repositioning may resolve the patient’s complaints, and caloric testing may not be required. If caloric testing is planned, it should be scheduled after any other tests planned for that day, as patients occasionally become nauseous and refuse any additional testing. This is also true, but much more infrequent, with rotational chair. Posturography may be done at any time that is convenient for the clinic. A full battery of tests can take up to three hours. Many elderly patients become fatigued, which can affect test performance. The evaluation can be broken up over two visits.
