Dix-Hallpike Maneuver

Aka: Dix-Hallpike Maneuver

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II. Indication

  1. Vestibular Testing for Benign Paroxysmal Positional Vertigo
    1. Vertigo evoked by position change (triggered Vertigo)
    2. No symptoms at rest

III. Contraindications

  1. Elderly with significant carotid vascular disease
  2. Unstable spinal disorder
  3. Acute vesitibular syndrome (non-triggered Vertigo)

IV. Procedure

  1. Patient starts in sitting position on exam table
    1. Facing forward with eyes open
  2. Rapidly lie patient backward (patient keeps eyes open and focused)
    1. Head turned 45 degrees to RIGHT
    2. Neck extended 20 degrees hanging over end of table
    3. Patient remains in this position for 30 seconds
    4. Vertigo or Nystagmus suggests right ear vestibular canal involvement
  3. Sit patient up
  4. Rapidly lie patient backward (patient keeps eyes open and focused)
    1. Head turned 45 degrees to LEFT
    2. Neck extended 20 degrees hanging over end of table
    3. Patient remains in this position for 30 seconds
    4. Vertigo or Nystagmus suggests left ear vestibular canal involvement
  5. Observe for symptoms triggered by Vertigo (lasting a minute or less)
    1. Vertiginous symptoms
    2. Nystagmus
      1. Upbeat or torsional Nystagmus (posterior canal)
      2. Downbeat Nystagmus (anterior canal)

V. Interpretation

  1. Tests only anterior and posterior canal
    1. Horizontal canal is NOT tested (but could be tested with a supine roll test)
  2. Positive signs suggestive of Benign Paroxysmal Positional Vertigo
    1. Vertigo
    2. Nystagmus
      1. Downbeat Nystagmus (anterior canal)
      2. Upbeat Nystagmus (posterior canal)
      3. Rotary or torsional Nystagmus (posterior canal)
        1. Globe torques around central axis
        2. Counterclockwise or clockwise
    3. Latent period (1 to 10 seconds) follows procedure before Nystagmus, Vertigo
    4. Response Fatigues or habituates on repetition

VI. Efficacy

  1. See HiNTs Exam (Three-Step Bedside Oculomotor Examination) as a better alternative for the acute Vertigo evaluation
  2. Identifies the affected ear in BPPV
  3. Unreliable in distinguishing peripheral Vertigo from central Vertigo (Cerebrovascular Accident)
    1. Kerber (2009) Emerg Med Clin North Am 27(1): 39-50 [PubMed]

VII. References

  1. Warrington (2022) Crit Dec Emerg Med 36(12): 16-7

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