Which physical findings are characteristic of benign paroxysmal positional vertigo (BPPV)?

Updated: Mar 13, 2020
  • Author: John C Li, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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  • The physical examination findings in patients affected by BPPV are generally unremarkable. All neurotologic examination findings except those from the Dix-Hallpike maneuver may be normal. However, the presence of neurotologic findings does not preclude the diagnosis of BPPV.

  • The Dix-Hallpike maneuver is the standard clinical test for BPPV. The finding of classic rotatory nystagmus with latency and limited duration is considered pathognomonic. A negative test result is meaningless except to indicate that active canalithiasis is not present at that moment.

    • This test is performed by rapidly moving the patient from a sitting position to the supine position with the head turned 45° to the right. After waiting approximately 20-30 seconds, the patient is returned to the sitting position. If no nystagmus is observed, the procedure is then repeated on the left side.

    • Dix-Hallpike maneuver tips include the following:

      • Do not turn the head 90° since this can produce an illusion of bilateral involvement.

      • Tailor briskness of the Dix-Hallpike test to the individual patient.

      • Consider the Epley modification. From behind the patient, performing the maneuver is easier, since one can pull the outer canthus superolaterally to visualize the eyeball rotation.

      • In typical nystagmus, the axis is near the undermost canthus. Minimize suppression by directing the patient gaze to the anticipated axis of rotation.

  • Classic posterior canal BPPV produces geotropic rotatory nystagmus. The top pole of the eyes rotates toward the undermost (affected) ear.

  • Purely horizontal nystagmus indicates horizontal canal involvement.

  • Sustained or nonfatiguing nystagmus may indicate cupulolithiasis rather than canalithiasis.

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