Cervical and Ocular VEMPs: from Otolith Physiology to Clinical Algorithms — A Narrative Review

Vestibular-evoked myogenic potentials (VEMPs)—cervical (cVEMP) and ocular (oVEMP)—are short-latency reflexes to air-conducted sound (ACS) or bone-conducted vibration (BCV) that probe otolith– brainstem–muscle pathways. To synthesize the physiological foundations (sustained vs transient otolith systems) and the clinical signatures of cVEMP/oVEMP across common vestibulopathies, and highlight high-frequency paradigms relevant to third-window disorders. Narrative synthesis of foundational physiology, translational studies, and clinical series for vestibular neuritis, Ménière’s disease (MD), and superior semicircular canal dehiscence (SCD). Clinical ACS/BCV robustly recruits irregular otolith afferents (transient system), generating a contralateral oVEMP n10 and an ipsilateral cVEMP p13–n23. In superior vestibular neuritis (SVN) the oVEMP n10 is reduced/absent beneath the contralesional eye while cVEMP is typically preserved; the complementary dissociation characterizes inferior vestibular neuritis (IVN). In MD, attack-phase testing often reveals utricular “enhancement” (oVEMP↑) with concurrent saccular reduction (cVEMP↓) relative to quiescence. For SCD, a single 4,000‑Hz oVEMP trial is a rapid, specific functional screen, with a clear canal–otolith mechanism. Conclusions. Interpreting VEMPs within the sustained/transient framework clarifies why 500‑Hz stimuli are efficient for routine testing and why reflex projection—not stimulus type—confers utricular (oVEMP) vs saccular (cVEMP) weighting. A standardized oVEMP/cVEMP + vHIT battery improves lesion localization, follow-up, and triage for SCD (Curthoys et al., 2017; Curthoys et al., 2018; Manzari et al., 2013; Curthoys & Manzari, 2020).