Vestibular —
Training activity: 4

Details

Interpret and integrate results from the following standard tests to formulate a differential diagnosis:

• Videonystagmography, including static body positional testing and headshake test
• Caloric testing (with the aid of an assistant)
• Video head impulse test
• Vestibular-evoked myogenic potential testing (either cervical or ocular)

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Considerations

• Integration of results with history to form a diagnosis
• Test limitations
• Physiology underlying the tests and how this relates to diagnosis
• Age-related differences in normal test performance
• Recognition of artefacts
• Signs of central dysfunction

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

• What does success look like?
  • What constitutes successfully interpreting and integrating the results from this entire test battery (VNG, Calorics, vHIT, VEMP) to formulate an accurate differential diagnosis?
  • Have you discussed expectations for result synthesis and diagnosis with your training officer?
• What is your prior experience of this activity?
  • Have you previously interpreted and synthesised this specific range of vestibular test results?
  • What do you already know about the interpretation, limitations, and inter-relationship of these tests?
  • What specific challenges related to managing conflicting results, differentiating central versus peripheral lesions, or handling findings for rare vestibular conditions might you face. How might you plan to handle them?
  • What is the scope of your own practice for interpreting and diagnosing vestibular conditions? When must you recognise that something is beyond your scope and seek advice or escalation?
  • How do you feel about interpreting complex and integrated vestibular data?
• What do you anticipate you will learn from the experience?
  • What specific skills in test result synthesis and differential diagnosis formulation do you want to develop or refine, drawing upon previous experiences?
  • What specific insights into the presentation and diagnosis of specific conditions (e.g., Meniere’s disease, chronic vestibulopathy, central lesions) do you hope to gain?
• What additional considerations do you need to make?
  • Have you reviewed any actions identified from your previous reflections on interpreting objective test results?
  • Do you need to review the expected findings for the differential diagnoses relevant to this activity (e.g., unilateral weakness, BPPV, central findings)?

In action

• During the activity is anything unexpected occurring?
  • Are you noticing anything surprising or different from what you anticipate when reviewing the test results? Are you encountering situations such as:
    • Results that conflict significantly across the test battery (e.g., normal vHIT but abnormal calorics, or positive VEMPs suggesting a third window syndrome not supported by history)?
    • Objective findings that do not logically align with the patient’s subjective history and functional impact?
    • The test pattern suggesting a Central finding that necessitates immediate escalation or specialised input?
  • How does this experience compare with previous experiences of similar activities?
• How are you reacting to the unexpected development?
  • How is the unexpected development being resolved as you progress during the activity? Are you successfully managing the interpretation yourself (e.g., reconciling conflicting results), or do you need support because the findings suggest a central vestibular finding that requires multi-disciplinary review or onward referral?
  • What are you learning in this moment as a result of the unexpected development? For example, are you learning a clearer method for synthesising data when results appear contradictory, or deepening your understanding of how subtle objective findings relate to the patient’s functional impact?
  • How is this impacting your actions?
    • Are you responding to the situation appropriately (e.g., pausing interpretation to verify the reliability of the measurements)? Are you adapting or changing your approach to interpretation (e.g., prioritising one test modality over another based on the clinical presentation)?
    • Is this unexpected event affecting your ability to undertake the activity independently?
    • Specifically, are you immediately cross-referencing the results with the established evidence base for vestibular disorders?
  • How are you feeling in this moment? For example, are you finding it difficult to adapt? Is it affecting your confidence in formulating the differential diagnosis? Are you feeling positive you can reach a successful conclusion?
• What is the conclusion or outcome?
  • How are you working within your scope of practice? E.g. Are you successfully interpreting and integrating the results, ensuring that the differential diagnosis formulated aligns with the established evidence base for vestibular disorders? Are you recognising when the integrated results suggest a central vestibular finding and escalating the case for multi-disciplinary review or onward referral?
  • What are you learning as a result of the unexpected development? E.g. Are you learning a clearer method for synthesising data when results across different tests appear contradictory? Are you deepening your understanding of how subtle objective findings relate to the patient’s subjective history and functional impact?

On action

• What happened?
  • Begin by summarising the key points of how you interpreted and integrated the results from the standard tests to formulate a differential diagnosis.
  • Consider specific events, actions, or thought processes that felt important, such as reconciling conflicting data or linking findings to pathology. How did you feel during the interpretation process?
  • Include any ‘reflect-in-action’ moments, where you adapted your interpretation strategy when encountering ambiguous or conflicting results.
• How has this experience contributed to your developing practice?
  • What learning can you take from interpreting and integrating these specific test results?
  • What strengths did you demonstrate in formulating the differential diagnosis? What skills or knowledge gaps were evident (e.g., related to understanding specific test findings, integrating results from different tests, considering differential diagnoses)?
  • How did this experience compare against previous engagements with similar activities? Were any previous identified actions for development achieved? Has your practice improved?
  • Identify any challenges you experienced (e.g., ambiguous findings, conflicting results, difficulty linking findings to pathology) and how you reacted to these. Did these challenges affect your ability to deal with the situation? Were you able to overcome them?
  • Was there anything significant about this activity, such as needing to seek advice or clarification on interpretation, or considering if you were working within your scope of practice?
• What will you take from this experience moving forward?
  • Identify the actions or ‘next steps’ you will now take to support the assimilation of what you have learnt, including from any feedback you received.
  • What will you do differently next time you interpret and integrate vestibular test results?
  • Has anything changed in terms of what you would do if you were faced with a similar situation again?
  • Do you need to practise any aspect of interpretation or differential diagnosis formulation further? E.g.
    • Reviewing the relationship between VEMP, vHIT, and Caloric findings to strengthen your ability to integrate results across the full test battery.
    • Seeking supervision on formulating a differential diagnosis when results are ambiguous or appear conflicting, such as mild asymmetry on calorics but normal vHIT.
    • Researching specific pathology patterns (e.g., Meniere’s disease progression, central signs) to improve the speed and accuracy of your interpretation.
    • Practising clear documentation of the diagnostic process, outlining how test results led to the differential diagnosis.

Beyond action

• Have you revisited the experiences?
  • Have you revisited your previous reflections (reflect-before-action, reflect-in-action, and reflect-on-action) for this specific activity (interpreting and integrating results to formulate a differential diagnosis)?
  • When reviewing these past reflections, what actions for improvement did you previously identify you would need to take to improve your practice related to reconciling conflicting test data, linking specific test patterns to known pathologies (e.g., Meniere’s, BPPV, central lesions), or clearly justifying your differential diagnosis?
  • Have you completed these previously identified actions? If not, what are the barriers? If so, how did completing them impact your subsequent performance of this activity? Are you ready to demonstrate this new learning confidently and consistently when performing this task?
  • Have you engaged in professional storytelling or discussed your experiences of interpreting complex test batteries with peers, near peers, or colleagues? Has discussing these experiences with others changed your view or understanding of the inter-relationship and limitations of specific tests or diagnostic pathways?
• How have these experiences impacted upon current practice?
  • Considering your cumulative experiences and reflections on this activity, how will the learning you have gained support you in preparing for relevant observed ‘in-person’ assessments for the module? For example, how does your improved understanding and skill in interpreting results prepare you for Case-Based Discussions (CBDs) where you must present and justify your diagnostic conclusion?
  • How has your practice related to interpreting and integrating test results to formulate a differential diagnosis developed and evolved over time across multiple instances of undertaking this training activity? Can you identify specific examples of improvement or increased confidence in synthesising findings across the battery, identifying subtle central signs, or confidently ruling out certain pathologies?
  • Based on your experiences, how has your ability to recognise when something related to interpretation is beyond your scope of practice improved? Do you have a clearer understanding of when and from whom (e.g., supervisor, medical specialist, vestibular specialist) you need to seek advice or clarification regarding highly ambiguous results, suspected non-vestibular causes of dizziness, or complex central diagnoses?

Relevant learning outcomes

#	Outcome
# 2	Outcome Perform vestibular assessments making safe and appropriate adaptions to the test approach to suit the needs of the patient.
# 3	Outcome Perform and interpret a wide range of diagnostic vestibular tests.