Is vertigo caused by turning my head to the left indicative of a problem with my left ear?

Determining the Affected Ear in Positional Vertigo

When vertigo is triggered by turning the head to the left, this does not necessarily indicate that the left ear is the affected ear in benign paroxysmal positional vertigo (BPPV). 1

Diagnostic Approach for Lateral Canal BPPV

• The supine roll test (Pagnini-Lempert or Pagnini-McClure Roll Test) is the preferred diagnostic maneuver to determine which ear is affected when head turning causes vertigo 1
• This test involves:
  • Positioning the patient supine with head in neutral position
  • Quickly rotating the head 90° to one side and observing for nystagmus
  • Returning to neutral position after nystagmus subsides
  • Rotating the head 90° to the opposite side and again observing for nystagmus 1

Interpreting Nystagmus Patterns

• Two types of nystagmus patterns may occur during the supine roll test:
  • Geotropic type (more common): Horizontal nystagmus beating toward the ground (undermost ear)
    • The affected ear is the one where rotation produces the most intense nystagmus 1
  • Apogeotropic type (less common): Horizontal nystagmus beating toward the uppermost ear
    • The affected ear is typically opposite to the side with the strongest nystagmus 1

Important Diagnostic Considerations

• Direction-changing positional nystagmus is the hallmark of lateral canal BPPV, where nystagmus direction changes with changes in head position 1
• In geotropic lateral canal BPPV, debris is likely located in the long arm of the semicircular canal 1
• In apogeotropic lateral canal BPPV, debris is likely adherent to or near the ampulla of the semicircular canal 1
• Despite careful testing, determining the affected side remains unclear in about 20% of cases 1

Additional Diagnostic Methods

• When standard testing is inconclusive, additional methods to determine the affected ear include:
  • Lying-down nystagmus test: Observing nystagmus when moving from sitting to straight supine position 1, 2
  • Head pitch test: Observing nystagmus when the patient sits up from supine position and bends the head down 1, 2
  • Bow and lean test: Observing nystagmus direction when the patient bends forward and backward 1, 2

Clinical Pitfalls to Avoid

• Don't assume the side to which head turning triggers vertigo is automatically the affected ear 1
• Be aware that BPPV is often misdiagnosed or underdiagnosed despite being the most common cause of peripheral vertigo 1, 3
• Exercise caution when performing diagnostic maneuvers in patients with cervical stenosis, limited cervical range of motion, severe kyphoscoliosis, cervical radiculopathies, ankylosing spondylitis, spinal cord injuries, or morbid obesity 1, 2
• Remember that lateral canal BPPV can occur following treatment maneuvers for posterior canal BPPV (canal switch) 1

Differential Diagnosis Considerations

• Other causes of vertigo that may present similarly include vestibular neuritis, Ménière's disease, migraine, and less commonly, vertebrobasilar ischemia 4, 5
• A thorough diagnostic approach is essential to distinguish between peripheral causes (inner ear) and central causes (brainstem or cerebellum) of vertigo 6, 7