Skew deviation is a vertical ocular misalignment caused by the disruption of the utriculo-ocular motor pathway—a brainstem-mediated reflex arc essential for maintaining visual and postural orientation in response to gravity. Physiologically, this system generates the ocular tilt reaction (OTR)—a triad of head tilt, ocular counter-roll, and subtle vertical skewing—to maintain spatial orientation. When pathologic, these signs can serve as precise localizing tools. This chapter reviews the anatomy and clinical implications of skew deviation, presenting three illustrative cases that trace the same vestibular pathway from the inner ear to the midbrain, each producing similar clinical findings from lesions at different levels. The presence of skew deviation in conjunction with other ocular motor or neurologic signs (“the company it keeps”) improves localization. Differentiating skew from CN IV palsy is crucial, as misdiagnosis may delay life-saving neuroimaging. Ultimately, this chapter highlights how a nuanced understanding of vestibular neuroanatomy, combined with careful clinical examination, can yield powerful diagnostic and localizing insights in patients with acute dizziness and diplopia.