How do you assess for Benign Paroxysmal Positional Vertigo (BPPV)?

From the Guidelines

Benign Paroxysmal Positional Vertigo (BPPV) is best assessed using the Dix-Hallpike maneuver and the supine roll test, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1.

Assessment of BPPV

The Dix-Hallpike maneuver is performed by having the patient sit upright on an examination table, then quickly moving them into a supine position with their head hanging 30 degrees over the edge and turned 45 degrees to one side. The position is held for 30 seconds while observing for nystagmus (involuntary eye movements) and asking about vertigo symptoms. The test is repeated with the head turned to the opposite side. A positive test shows delayed onset (typically 1-5 seconds) of rotatory nystagmus and vertigo that lasts less than one minute.

• The supine roll test is used to assess horizontal canal BPPV by having the patient lie supine with their head elevated 30 degrees, then quickly rotating their head 90 degrees to each side while watching for horizontal nystagmus.
• These tests are diagnostic because BPPV results from displaced calcium carbonate crystals (otoconia) in the semicircular canals that move with position changes, causing inappropriate endolymph flow and resulting in the characteristic brief, position-induced vertigo and nystagmus.
• Additional assessment should include questions about vertigo triggers, duration, associated symptoms, and medication use to rule out other causes of dizziness.

Importance of Accurate Diagnosis

Accurate diagnosis of BPPV is crucial to prevent unnecessary testing and treatment, and to improve patient outcomes. The Dix-Hallpike maneuver and supine roll test are essential components of the diagnostic evaluation, and should be performed by a trained clinician.

• Clinicians should not obtain radiographic imaging or order vestibular testing in patients who meet diagnostic criteria for BPPV, unless there are additional signs or symptoms that warrant further evaluation 1.
• The diagnosis of BPPV is based on the clinical history and physical examination, and an appropriate canalith repositioning procedure (CRP) can be implemented immediately after diagnosis.

Conclusion is not allowed, so the response is ended here.

From the Research

Assessment of Benign Paroxysmal Positional Vertigo (BPPV)

To assess for BPPV, the following methods can be used:

• Dix-Hallpike test for posterior and anterior canals 2
• Supine roll test for the horizontal canal 3, 2
• Side-lying test as an alternative for patients who cannot perform the Dix-Hallpike test 2

Diagnostic Criteria

The diagnosis of BPPV can be established through:

• Clinical history 3
• Positive Dix-Hallpike or supine roll test result 3, 2
• Presence of vertigo and nystagmus during the test 4

Test Characteristics

The Dix-Hallpike test has:

• Sensitivity of 79% (95% CI 65-94) 2
• Specificity of 75% (33-100) 2
• Positive likelihood ratio of 3.17 (95% CI 0.58-17.50) 2
• Negative likelihood ratio of 0.28 (95% CI 0.11-0.69) 2

The side-lying test has:

• Sensitivity of 90% (95% CI 79-100) 2
• Specificity of 75% (33-100) 2
• Positive likelihood ratio of 3.59 (95% CI 0.65-19.67) 2
• Negative likelihood ratio of 0.14 (95% CI 0.04-0.46) 2

Treatment Outcomes

Treatment of BPPV with canalith repositioning manoeuvres (CRP) can be effective, with:

• 91% of posterior canal BPPV cases treated in 2 manoeuvres or less 4
• 88% of horizontal canal BPPV cases treated in 2 manoeuvres or less 4
• Repeated testing and treatment within the same session can be a safe and effective approach 4