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

From the Guidelines

The Dix-Hallpike maneuver is the primary test for diagnosing Benign Paroxysmal Positional Vertigo (BPPV), particularly for the posterior semicircular canal which is most commonly affected. To perform this test, have the patient sit upright on an examination table, then quickly move them into a supine position with their head hanging about 30 degrees below the horizontal plane and turned 45 degrees to one side. Hold this position for 30 seconds while observing for nystagmus (involuntary eye movements) and asking about vertigo symptoms. A positive test shows a brief latency period (1-5 seconds) followed by rotatory nystagmus and vertigo that lasts less than one minute. The test should be repeated with the head turned to the opposite side to test both ears. For horizontal canal BPPV, the Roll test (Pagnini-McClure test) is used instead, where the patient lies supine and their head is quickly rotated 90 degrees to each side. BPPV occurs when calcium carbonate crystals (otoconia) become dislodged from the utricle and move into the semicircular canals, causing inappropriate fluid movement and false sensation of motion when the head position changes. These tests help determine which ear and which canal is affected, guiding appropriate treatment with specific repositioning maneuvers 1.

Key Points to Consider

• The Dix-Hallpike maneuver is considered the gold standard test for the diagnosis of posterior canal BPPV.
• The test should be performed bilaterally to determine which ear is involved or if both ears are involved.
• 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.
• The Dix-Hallpike maneuver should be avoided in certain circumstances, such as 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.
• The test has a sensitivity of 82% and specificity of 71% for the diagnosis of posterior canal BPPV, primarily among specialty clinicians 1.

Important Considerations for Testing

• The patient should be oriented so that, in the supine position, the head can “hang” with support off the posterior edge of the examination table by about 20 degrees.
• The examiner should ensure that he can support the patient’s head and guide the patient through the maneuver safely and securely, without the examiner losing support or balance himself.
• The examination of the left side completes the test.
• 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.

Treatment and Management

• The treatment of BPPV typically involves specific repositioning maneuvers, such as the canalith repositioning procedure (CRP) or the Epley maneuver.
• The goal of these maneuvers is to guide the calcium carbonate crystals (otoconia) back to their normal position in the utricle, relieving the symptoms of vertigo and dizziness.
• In some cases, vestibular rehabilitation therapy (VRT) may be recommended to help improve balance and reduce symptoms of dizziness and vertigo 1.

From the Research

Diagnostic Tests for BPPV

• The Dix-Hallpike test is a commonly used diagnostic test for Benign Paroxysmal Positional Vertigo (BPPV) 2, 3, 4, 5.
• The test involves a series of maneuvers that can induce nystagmus (involuntary eye movement) in patients with BPPV.
• The sensitivity and specificity of the Dix-Hallpike test have been reported to be 79% and 75%, respectively 3.
• Alternative tests, such as the side-lying test, can be used in patients who are unable to perform the Dix-Hallpike test 3.

Diagnostic Value of Repeated Dix-Hallpike Maneuvers

• Repeating the Dix-Hallpike maneuver can increase the diagnostic yield in patients with BPPV 2.
• A study found that performing the diagnostic maneuvers only one more time in vertigo patients in the first clinical evaluation increases the diagnosis success in BPPV 2.
• The study also found that canalith repositioning maneuvers are effective and satisfactory treatment methods in BPPV 2.

BPPV without Nystagmus

• BPPV can occur without nystagmus, making diagnosis more challenging 6.
• A non-systematic review found that the treatment of BPPV without nystagmus was made by Epley maneuvers, Sémont, modified releasing for posterior semicircular canal and Brandt-Daroff exercises 6.
• The review found that 50% to 97.1% of patients with BPPV without nystagmus had symptom remission, while patients with BPPV with nystagmus had symptom remission ranging from 76% to 100% 6.

New Maneuvers for Diagnosing BPPV

• A new maneuver has been developed to rapidly restore positional nystagmus from BPPV fatigue in patients with posterior canal-type BPPV 4.
• The study found that the new maneuver successfully restores positional nystagmus and demonstrates its potential applicability in clinical practice for diagnosing pc-BPPV in cases complicated by BPPV fatigue 4.

Association between Dix-Hallpike Test Parameters and Treatment Efficacy

• A study investigated the parameters of positional nystagmus in the Dix-Hallpike test as prognostic factors for unilateral psc-BPPV 5.
• The study found that decreased vertical time course during slow phase nystagmus on the affected side and increased vertical velocity amplitude in the Dix-Hallpike test during slow phase nystagmus were associated with resistance to the canalith repositioning procedure 5.