See the list below:
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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.
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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.
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Classic posterior canal BPPV produces geotropic rotatory nystagmus. The top pole of the eyes rotates toward the undermost (affected) ear.
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Purely horizontal nystagmus indicates horizontal canal involvement.
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Sustained or nonfatiguing nystagmus may indicate cupulolithiasis rather than canalithiasis.
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The patient is placed in a sitting position with the head turned 45° towards the affected side and then reclined past the supine position.
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The patient is then brought back up to the sitting position.
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Next, the patient is rolled 180° from the affected side to the opposite side. Note that the position of the head is 45° toward the affected side before the roll. The head winds up facing down, 180° away from the starting position.
