What is the Dix-Hallpike (Dix-Hallpike test) maneuver?

From the Guidelines

The Dix-Hallpike maneuver is a diagnostic test used to identify benign paroxysmal positional vertigo (BPPV), particularly of the posterior semicircular canal, and it should be performed by turning the patient's head 45 degrees to one side, then quickly laying them back so their head hangs slightly over the edge of the table, maintaining the 45-degree rotation, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1. To perform this test, the patient begins in a seated position on an examination table. The examiner observes the patient's eyes for nystagmus (involuntary eye movements) and asks about vertigo symptoms. A positive test shows a characteristic delayed onset of rotatory nystagmus (typically after 1-5 seconds) that lasts less than one minute, accompanied by vertigo. The test should be repeated on the opposite side if initially negative. The Dix-Hallpike works by moving otoconia (calcium carbonate crystals) that have become dislodged in the semicircular canals, triggering abnormal fluid movement and resulting vertigo. This test is essential for proper diagnosis of BPPV before proceeding with appropriate treatment, such as the Epley maneuver. Some key points to consider when performing the Dix-Hallpike maneuver include:

• The test should be performed bilaterally to determine which ear is involved or if both ears are involved 1.
• Factors that may affect the diagnostic accuracy of the Dix-Hallpike maneuver include the speed of movements during the test, time of day, and the angle of the plane of the occiput during the maneuver 1.
• The Dix-Hallpike maneuver is considered the gold standard test for the diagnosis of posterior canal BPPV, with a sensitivity of 82% and specificity of 71% in specialty clinicians, and a positive predictive value of 83% and negative predictive value of 52% in primary care settings 1.
• A negative Dix-Hallpike maneuver does not necessarily rule out a diagnosis of posterior canal BPPV, and the test may need to be repeated at a separate visit to confirm the diagnosis and avoid a false-negative result 1.
• The Dix-Hallpike maneuver should be avoided in certain circumstances, such as in patients with significant vascular disease, 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, and morbid obesity 1.
• Special tilting examination tables may be necessary for patients with physical limitations to allow the safe performance of the Dix-Hallpike maneuver 1.
• Clinicians should not obtain radiographic imaging in a patient who meets diagnostic criteria for BPPV in the absence of additional signs and/or symptoms inconsistent with BPPV that warrant imaging, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1.
• Clinicians should not order vestibular testing in a patient who meets diagnostic criteria for BPPV in the absence of additional vestibular signs and/or symptoms inconsistent with BPPV that warrant testing, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1.
• The Dix-Hallpike maneuver is a crucial diagnostic tool for BPPV, and its proper performance and interpretation are essential for accurate diagnosis and effective treatment, as emphasized by the American Academy of Otolaryngology-Head and Neck Surgery 1.

From the Research

Dix-Hallpike Test

• The Dix-Hallpike test is a bedside test used to diagnose benign paroxysmal positional vertigo (BPPV) 2, 3, 4, 5
• It is a simple and reliable test that can be performed in an emergency department or clinical setting 2, 3
• The test involves moving the patient's head and body into specific positions to elicit symptoms of vertigo and nystagmus 4

Diagnostic Value

• The Dix-Hallpike test has a sensitivity of 79% and specificity of 75% in diagnosing posterior semicircular canal BPPV 4
• The test can also be used to diagnose other types of BPPV, including horizontal canal BPPV 2
• Repeated Dix-Hallpike and roll maneuvers can increase the diagnostic success in BPPV 5

Clinical Application

• The Dix-Hallpike test is underutilized in emergency departments, with only 53% of patients with symptoms consistent with BPPV undergoing the test 3
• The test is also frequently applied to patients whose symptoms are not consistent with BPPV, which can result in prolonged patient discomfort and increased resource utilization 3
• The Dix-Hallpike test can be used in conjunction with other diagnostic maneuvers, such as the Epley maneuver, to treat BPPV 2, 6

Special Considerations

• Some patients may not exhibit nystagmus during the Dix-Hallpike test, but still have BPPV 6
• In these cases, diagnosis and treatment can be based on clinical history and physical examination 6
• Alternative tests, such as the side-lying test, can be used in patients who are unable to undergo the Dix-Hallpike test 4