What is the diagnostic approach for Benign Paroxysmal Positional Vertigo (BPPV)?

Diagnosing Benign Paroxysmal Positional Vertigo (BPPV)

The diagnosis of BPPV should be made through the Dix-Hallpike maneuver for posterior canal BPPV and the supine roll test for lateral canal BPPV, without routine neuroimaging or vestibular testing unless additional symptoms inconsistent with BPPV are present. 1

Diagnostic Approach

Step 1: Clinical History Assessment

Look for these specific symptoms:

• Episodes of vertigo triggered by changes in head position relative to gravity
• Brief rotational vertigo lasting less than 60 seconds
• Symptoms provoked by specific movements:
  • Rolling over in bed
  • Tilting head upward (looking up at shelves)
  • Bending forward (tying shoes)
• Possible associated symptoms: lightheadedness, nausea, feeling "off balance"
• Approximately 50% of patients report subjective imbalance between episodes 1

Step 2: Posterior Canal BPPV Testing (Most Common Type)

Perform the Dix-Hallpike maneuver:

1. Position the patient seated upright
2. Turn the patient's head 45° to the side being tested
3. Quickly move the patient from sitting to supine position with the head extended 20° below horizontal
4. Observe for nystagmus and ask about vertigo
5. Return patient to sitting position
6. Repeat for the opposite side if initial test is negative

Positive diagnostic criteria:

• Vertigo with nystagmus provoked by the maneuver
• Latency period (typically 5-20 seconds) between maneuver completion and symptom onset
• Torsional, upbeating nystagmus
• Symptoms resolve within 60 seconds from onset 1

Step 3: Lateral (Horizontal) Canal BPPV Testing

If Dix-Hallpike is negative or shows horizontal nystagmus, perform the supine roll test:

1. Position patient supine with head in neutral position
2. Quickly rotate head 90° to one side
3. Observe for nystagmus
4. Return head to neutral position
5. After nystagmus subsides, rotate head 90° to opposite side
6. Observe for nystagmus 1

Two possible nystagmus patterns:

• Geotropic type (more common): Intense horizontal nystagmus beating toward the undermost ear
• Apogeotropic type: Horizontal nystagmus beating toward the uppermost ear 1

Step 4: Repeat Testing If Necessary

If initial testing is negative but clinical suspicion remains high:

• Repeat the Dix-Hallpike test during the same visit
• The sensitivity of a single Dix-Hallpike test is limited (reported as 82% with specificity of 71%) 1
• Repeating the maneuver can improve diagnostic yield by allowing canaliths to collect in a position that will produce a positive test 2, 3

Important Diagnostic Considerations

When to Avoid Standard Testing

Exercise caution with the Dix-Hallpike maneuver in patients with:

• Cervical stenosis
• Severe kyphoscoliosis
• Limited cervical range of motion
• Down syndrome
• Severe rheumatoid arthritis
• Cervical radiculopathies
• Paget's disease
• Ankylosing spondylitis
• Low back dysfunction
• Spinal cord injuries
• Morbid obesity 1

When NOT to Order Additional Testing

• Neuroimaging: Do not obtain radiographic imaging in patients who meet diagnostic criteria for BPPV without additional signs/symptoms inconsistent with BPPV 1
• Vestibular testing: Do not order vestibular testing in patients who meet diagnostic criteria for BPPV without additional vestibular signs/symptoms inconsistent with BPPV 1

When to Consider Additional Testing

Consider neuroimaging or vestibular testing when:

• Clinical presentation is atypical
• Dix-Hallpike testing elicits equivocal or unusual nystagmus
• Diagnosis remains unclear after positional testing
• Additional symptoms beyond those attributable to BPPV are present
• Multiple concurrent peripheral vestibular disorders are suspected 1

Common Pitfalls to Avoid

1. Missing lateral canal BPPV: Always test for lateral canal BPPV if posterior canal testing is negative
2. Single testing only: False negatives can occur with a single Dix-Hallpike test; consider repeating the test during the same visit 2, 3
3. Overlooking post-traumatic BPPV: Consider BPPV in patients with dizziness after head trauma 4
4. Unnecessary imaging: Routine neuroimaging is not justified in typical BPPV cases and does not improve diagnostic accuracy 1
5. Failure to differentiate from other causes: Always consider other causes of vertigo when presentation is atypical 1

By following this systematic diagnostic approach, BPPV can be accurately diagnosed in most cases without unnecessary testing, allowing for prompt and effective treatment with appropriate repositioning maneuvers.