What tests are used to diagnose Benign Paroxysmal Positional Vertigo (BPPV)?

Diagnostic Tests for Benign Paroxysmal Positional Vertigo (BPPV)

The primary diagnostic tests for BPPV are the Dix-Hallpike maneuver for posterior canal BPPV and the supine roll test for lateral canal BPPV, with no need for imaging or laboratory testing when these tests are positive. 1

Primary Diagnostic Maneuvers

Dix-Hallpike Test (for Posterior Canal BPPV)

• Gold standard test for diagnosing posterior canal BPPV (the most common type, accounting for 85-95% of cases) 1, 2
• Performed by moving the patient from sitting to lying position with the head turned 45° to one side and extended 20° below horizontal 1
• A positive test shows:
  • Vertigo with torsional, upbeating nystagmus
  • Latency period of 5-20 seconds
  • Nystagmus and vertigo resolving within 60 seconds 2
• Sensitivity of 82% and specificity of 71% for posterior canal BPPV 1, 2
• The affected ear is the one facing downward during the positive test 2

Supine Roll Test (for Lateral Canal BPPV)

• Essential test for diagnosing lateral canal BPPV (5-15% of BPPV cases) 1
• Performed by:
  1. Positioning patient supine with head in neutral position
  2. Quickly rotating head 90° to one side
  3. Observing for nystagmus
  4. Returning head to neutral position
  5. Rotating head 90° to opposite side
  6. Observing for nystagmus again 1
• Two possible findings indicating lateral canal BPPV:
  • Geotropic nystagmus: beats toward the ground, stronger on the affected side
  • Apogeotropic nystagmus: beats away from the ground, stronger on the unaffected side 1, 2

Important Clinical Considerations

Repeated Testing

• A single negative test does not rule out BPPV 1
• Repeating diagnostic maneuvers in the same session can increase diagnostic yield by up to 13.5% 3
• BPPV fatigue phenomenon may cause diminished response that typically resolves within 30 minutes 2, 4

Multiple Canal Involvement

• Both Dix-Hallpike and supine roll tests should be performed in all suspected BPPV cases 5, 6
• Approximately 5.5% of patients show nystagmus in both tests 5
• Multiple canal involvement occurs in about 3.3% of cases 5

Bilateral BPPV

• Bilateral positive Dix-Hallpike test occurs in approximately 11.2% of BPPV cases 7
• Careful observation of nystagmus characteristics is essential to differentiate between:
  • True bilateral posterior canal BPPV
  • Horizontal canal BPPV mimicking bilateral posterior canal involvement
  • Unilateral posterior canal BPPV with contralateral down-beating nystagmus 7

What Not to Do

• Avoid unnecessary imaging (MRI, CT) when diagnostic criteria for BPPV are met 1, 8
• Avoid routine audiometry unless hearing loss is suspected 1
• Avoid vestibular function testing (electronystagmography, videonystagmography) when diagnosis is clear from positional testing 8
• Avoid vestibular suppressant medications like meclizine as they may delay recovery 2

Special Considerations

• Exercise caution when performing these tests in patients with:
  • Cervical stenosis
  • Severe kyphoscoliosis
  • Limited cervical range of motion
  • Severe rheumatoid arthritis
  • Cervical radiculopathies
  • Morbid obesity 1
• For patients with physical limitations, special tilting examination tables may allow safe performance of diagnostic maneuvers 1
• If both tests are negative but clinical suspicion remains high, consider referral to a specialist for additional testing 8