Beyond Tests: Reframing the Management of Chronic Unilateral Vestibular Hypofunction

Dear Editor,Recent studies suggest that the clinical management of chronic unilateral vestibular hypofunction (UVH) has been predominantly focused on diagnostic testing, while patient-centered assessments and subjective symptom burden remain underemphasised. Chronic UVH is a multidimensional vestibular disorder frequently encountered in clinical practice but often reduced to “dizziness” and “imbalance,” overlooking its broader impact (1). It refers to a condition in which, despite central compensation after unilateral vestibular loss, symptoms such as imbalance, oscillopsia, or motion-provoked complaints persist for 3 months or longer (2). This reductionist view may obscure the true functional limitations experienced by patients. In reality, chronic UVH is not only a peripheral disorder but also a complex condition with behavioural, cognitive, and psychosocial dimensions (3).The symptom spectrum of chronic UVH extends beyond dizziness and imbalance. Oscillopsia, visual sensitivity, cognitive fatigue, and avoidance of head movements can significantly impair daily life. As some of these symptoms are not spontaneously reported, focusing solely on vestibular-related physical complaints during anamnesis may lead to an incomplete clinical picture. Therefore, the impact of vestibular loss on daily functioning should be assessed systematically (3).A test-centered perspective remains common in diagnostic evaluation. Vestibular function tests are often treated as definitive indicators of functional status. However, no single test fully captures the patient’s symptom burden or disability in daily life (4). The caloric test, limited to low-frequency stimulation and influenced by anatomical variation, does not reflect natural head movements. On the other hand, the video head impulse test may appear normal in the chronic phase due to central compensation (5). Consequently, patients may continue to report significant symptoms despite normal test results, which emphasise a discrepancy between laboratory findings and real-life experience. The key issue is not which test is superior but that clinical decision-making is overly reliant on test outcomes. The aim of vestibular assessment should be to understand and reduce functional limitations rather than normalise laboratory parameters. Therefore, objective findings must be interpreted alongside subjective symptoms and functional outcomes.