Experience Summary

Benign Paroxysmal Positional Vertigo (BPPV), can be debilitating for patients. In this 360-degree video, observe the steps to diagnose BPPV with the Dix-Hallpike test.

Clinical Context

The Dix-Hallpike test is a positional manoeuvre used to diagnose BPPV, the most common cause of vertigo. BPPV occurs due to dislodged otoliths (calcium carbonate crystals) from the utricle, which migrate into the semicircular canals, typically the posterior canal, leading to abnormal endolymph movement and vertigo. Patients typically present with brief episodes of vertigo, often triggered by changes in head position such as looking up, rolling over in bed, or bending down. The Dix-Hallpike test reproduces symptoms and helps confirm the diagnosis.

Counselling Points:

Before performing the test, it is important to explain the following to the patient:

• Purpose: Explain that this test helps determine if their dizziness is due to a mechanical issue in the inner ear called BPPV, which is a common, non-serious cause of vertigo.
• What to Expect: The test may momentarily bring on dizziness, vertigo, or the sensation of spinning. Reassure the patient that this is normal and usually lasts less than a minute.
• Risks and Discomforts:
  • Common: Temporary dizziness, nausea, or imbalance.
  • Rare: Vomiting or, in rare cases, falls if not properly supported.
• Precautions: Encourage the patient to relax and inform them that their head and body will be supported throughout the test to prevent injury.
• Alternatives: There are other balance tests, but the Dix-Hallpike is the most effective for diagnosing BPPV.

Procedural Steps:

1. Preparation:
   • Obtain informed consent.
   • Ensure a safe environment with space to recline the patient.
   • Advise the patient to remove glasses or earrings if applicable.
2. Positioning:
   • The patient sits upright on an examination couch with their legs extended.
   • The examiner turns the patient’s head 45 degrees to the side being tested.
3. Test Execution:
   • While supporting the head, the examiner quickly brings the patient from sitting to a supine position with their head extended 20-30 degrees below the horizontal plane, maintaining the 45-degree head turn.
   • Observe the patient’s eyes for nystagmus (typically a torsional, up-beating nystagmus in posterior canal BPPV) and ask if vertigo occurs.
4. Interpretation:
   • A positive test is indicated by delayed onset vertigo and nystagmus.
   • If negative, the test is repeated on the opposite side.
5. Aftercare:
   • Allow the patient to rest until symptoms resolve.
   • If BPPV is confirmed, consider proceeding with a therapeutic manoeuvre such as the Epley manoeuvre.
   • Provide advice on symptom management and follow-up if necessary.

Learning Outcomes

1. Understand how to diagnose BPPV.
2. Understand the positioning of the patient relative to the examiner, and the subsequent movements required to perform the Dix-Hallpike test.
3. Understand the importance of counselling the patient appropriately prior to a potentially uncomfortable procedure.

External Resources

• StatPearls - Dix-Hallpike Test