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

From the Guidelines

The Dix-Hallpike maneuver is interpreted as positive when it reproduces vertigo and nystagmus in a patient with suspected benign paroxysmal positional vertigo (BPPV), with a sensitivity of 82% and specificity of 71% as reported by Lopez-Escamez et al 1. To perform the test, position the patient sitting upright, turn their head 45 degrees to one side, then quickly lay them back with their head hanging about 30 degrees below horizontal.

• A positive test for posterior canal BPPV typically shows a delayed onset (1-5 seconds) of vertigo and upbeating, torsional nystagmus that fatigues within 60 seconds.
• The nystagmus should have the fast phase beating toward the affected (down) ear.
• When testing the opposite side, if symptoms are reproduced, that indicates the affected ear.
• The test is negative if no nystagmus or vertigo occurs.
• Horizontal canal BPPV produces horizontal nystagmus instead. The latency, duration, and fatigability of symptoms are key diagnostic features that distinguish BPPV from central causes of vertigo, as stated in the clinical practice guideline: benign paroxysmal positional vertigo (update) executive summary 1. If the nystagmus is immediate, doesn't fatigue, or changes direction, consider central nervous system pathology rather than BPPV, as recommended by the guideline 1. Always document the side tested, presence and direction of nystagmus, and whether vertigo was reproduced, and consider repeating the test at a separate visit to confirm the diagnosis and avoid a false-negative result, as suggested by Hanley and O’Dowd 1.

From the Research

Interpreting Dix Hallpike Maneuver

The Dix Hallpike maneuver is a diagnostic test used to identify benign paroxysmal positional vertigo (BPPV) [(2,3,4,5,6)]. The test involves a series of movements that help to determine if the patient has BPPV.

• The test is considered positive if the patient experiences vertigo and nystagmus (abnormal eye movements) during the maneuver [(2,4)].
• The sensitivity of the Dix Hallpike test is estimated to be around 79% 4.
• The specificity of the Dix Hallpike test is estimated to be around 75% 4.
• A positive Dix Hallpike test can be converted to a negative test with the use of the canalith repositioning maneuver (CRM) [(2,3,5,6)].

Diagnostic Accuracy

The diagnostic accuracy of the Dix Hallpike test can be affected by various factors, including the patient's ability to move into the test positions 4. Alternative tests, such as the side-lying test, can be used in patients who are unable to move into the Dix Hallpike test positions 4.

• The side-lying test has a sensitivity of around 90% and a specificity of around 75% 4.
• The Dix Hallpike test is considered the standard test for diagnosing posterior semicircular canal BPPV 4.

Treatment and Recurrence

The canalith repositioning maneuver (CRM) is a effective treatment for BPPV [(2,3,5,6)].

• The CRM has a cure rate of around 80% at 24 hours 5.
• The recurrence rate of BPPV after treatment is around 36% 2.
• Vestibular rehabilitation in addition to CRM may not influence the positive to negative Dix Hallpike test, recurrence, or number of maneuvers to achieve a negative test in elderly patients with chronic BPPV 6.