How to perform a supine roll test on a patient with suspected lateral canal Benign Paroxysmal Positional Vertigo (BPPV) who had a failed Epley maneuver?

How to Perform the Supine Roll Test

The supine roll test is performed by positioning the patient supine with the head in neutral position, then rapidly rotating the head 90 degrees to one side while observing for horizontal nystagmus, waiting for symptoms to resolve, and repeating the maneuver to the opposite side. 1, 2, 3

Patient Preparation and Counseling

• Warn the patient that this test will likely provoke intense dizziness temporarily, as this is a provocative maneuver designed to elicit symptoms 1, 3
• Ensure you have assistance available if the patient is obese or has physical limitations, as additional support may be required 1

Step-by-Step Technique

Initial Positioning

• Position the patient supine (lying flat) with the head in neutral position (facing straight up toward the ceiling) 1, 2, 3

First Side Testing

• Quickly rotate the patient's head 90 degrees to one side (either right or left) 1, 2, 3
• Observe carefully for horizontal nystagmus (side-to-side eye movements, not torsional) 2, 3
• Note whether the nystagmus is geotropic (beating toward the ground/undermost ear) or apogeotropic (beating away from the ground/toward the uppermost ear) 2, 3
• Inquire about subjective vertigo 1
• Wait for the nystagmus and vertigo to subside before proceeding 1

Second Side Testing

• Return the head to neutral position 2
• Quickly rotate the head 90 degrees to the opposite side 1, 2, 3
• Again observe for horizontal nystagmus and note its direction and intensity 2, 3
• Inquire about subjective vertigo 1

Interpreting the Results

Identifying the Affected Ear

• In geotropic lateral canal BPPV (most common type), the side with the strongest/most intense nystagmus is the affected ear 2, 3
• In apogeotropic lateral canal BPPV, the side opposite the stronger nystagmus is the affected ear 2
• The affected ear identification is crucial for selecting the appropriate treatment maneuver 3

Understanding Nystagmus Patterns

• Geotropic nystagmus (beating toward the undermost ear on both sides) indicates canalolithiasis with debris in the long arm of the canal 2, 3
• Apogeotropic nystagmus (beating toward the uppermost ear on both sides) indicates debris adherent to or near the ampulla 2

Special Precautions

Exercise caution in patients with:

• Cervical stenosis, severe kyphoscoliosis, or limited cervical range of motion 1, 3
• Down syndrome, severe rheumatoid arthritis, or cervical radiculopathies 1
• Paget's disease, ankylosing spondylitis, low back dysfunction, or spinal cord injuries 1
• Morbid obesity (may require additional assistance) 1, 3
• Significant vascular disease (consider stroke or vascular injury risk) 1

Clinical Context

• Perform this test when the Dix-Hallpike maneuver is negative but the patient has a history compatible with BPPV (repeated episodes of vertigo with positional changes) 1, 2, 3
• Lateral canal BPPV accounts for 10-15% of all BPPV cases and is frequently missed when clinicians only perform Dix-Hallpike testing 1, 2, 3
• Lateral canal BPPV commonly occurs after performing the Epley maneuver for posterior canal BPPV due to "canal switch" where debris migrates from the posterior to lateral canal 1, 2
• Be aware that CNS adaptation may cause spontaneous nystagmus direction changes without head repositioning, which can confuse diagnosis 2
• In approximately 20% of lateral canal cases, lateralization may remain unclear despite proper testing 2