Dix-Hallpike Test: Physical Exam
- Perform on all patients complaining of dizziness/vertigo
- Tests for posterior canal benign paroxysmal positional vertigo (BPPV)
- The maneuver positions the posterior semicircular canal in a vertical orientation which causes the canalith particles to gravitate downward causes vertigo and nystagmus.
- The patient should be seated on the exam table so that when they lie down their head will extend over the end of the table. Note: Have someone stand on each side of the table while you perform this maneuver as some patients develop severe vertigo and fall off the table. Also, have a bucket nearby as patients occasionally vomit.
- Explain to the patient what is going to be done and that any dizziness will only last a few seconds.
- Maintain control of the patients head to be sure the maneuver is performed optimally and to provide maximal stimulation.
- Tell the patient to keep their eyes open and look directly at you at all times.
- Place one hand on top of the head and one hand under the chin.
- Have the patient go quickly from the sitting to the supine position, with their head hanging 10°-30° below horizontal, as you quickly turn their head toward you. Note: 1). The "down" ear is the one being tested. 2). If the patient can tall you which side down causes the vertigo, check the opposite side first to minimize nausea.
- Observe the patients eyes for at least 15 seconds to see whether nystagmus is induced. Note: The onset of nystagmus may have a latency period of several seconds and has a crescendo-decrescendo pattern of intensity
- Slowly bring the patient back to a sitting position, with the head still rotated.
- Check for nystagmus again. Note: The nystagmus should reverse rotation.
- Repeat the procedure with the head rotated the opposite direction.
- "down" side produces nystagmus and is the side causing the positional vertigo
- If the right side is being tested (in the "down" position), the eye will rotate in a counterclockwise manner during the rapid phase of nystagmus, with a minor up-beating vertical (toward the forehead) component
- If the left side is being tested, the results are similar except the eye rotates clockwise
- No nystagmus is noted
- Sensitivity for BPPV: 50%-78%
- Likelihood ratio (LR):
- A positive test combined with a history of vertigo or vomiting gives a LR of 7.6 for peripheral, nonemergent form of vertigo
- If vertigo/vomiting is lacking in a "dizzy" patient, the LR for peripheral, nonemergent vertigo as opposed to potentially emergent and/or central cause is 0.6
- Froehling DA et al. Does this dizzy patient have a serious form of vertigo? JAMA. 1994;271:385-388.
- Orient, JM. Sapira's Art and Science of Bedside Diagnosis. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins. 2010;562.
- Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ. 2003:169:681-693.
- Viirre E1, Purcell I, Baloh RW. The Dix-Hallpike test and the canalith repositioning maneuver. Laryngoscope. 2005 Jan;115(1):184-7.