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Vertigo - Dix Hallpike testing

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Indications

Paroxysmal vertigo

and

No nystagmus (prior to assessment)

Contraindications (absolute in bold)

Acute trauma

Cervical spine disease

Vascular insufficiency (carotid or vertebrobasilar)

Limited mobility

Alternatives

Inpatient tilt table testing (if available)

Informed consent

Verbal consent

Less complex non-emergency procedure with low risk of complications

Potential complications

Vertigo

Vomiting

Procedural hygiene

Standard precautions

PPE: non-sterile gloves

Area

Any bed space

Staff

Procedural clinician

Equipment

Bed with access on both sides

Stool or chair at foot of bed for procedural clinician

Positioning

Sit patient in bed, with head towards the foot of the bed

Adjust until patient’s head hangs extended 20 degrees over the end of the bed when supine

Patient’s head rotated 45 degrees towards the ear to be tested

Clinician sits behind patient on stool ready to support the head (forearm resting on thigh)

Medication

Consider ondansetron 4mg orally 30 minutes prior to procedure

Sequence

Explain the Dix-Hallpike test to patient, warning it may cause brief vertigo and nausea

Instruct patient to try and keep their eyes open

From sitting, lie patient down quickly head rotated to 45 degrees (ear being tested is faces down)

Adjust patient’s head position to maintain head rotation and extension to 20 degrees over the edge of the bed

Observe eyes for upwards and rotational nystagmus (a positive test for the ear pointing downwards)

If patient closes eyes, lift the eyelid briefly to examine for nystagmus

If the test is negative, allow the patient to recover and test the other ear

Post-procedure care

By test results:

No nystagmus on both sides:

Repeat the test (consider a more experienced provider)

Consider testing for lateral semi-circular canal BPPV with a supine roll test (if familiar with this)

Consider alternative diagnosis and discuss with speciality team (neurology, ENT or vestibular physiotherapy)

Upwards and rotational nystagmus diagnosing posterior canal BPPV:

Perform the Epley manoeuvre then wait 15 minutes

Reperform the Dix-Hallpike test (80% chance of resolution of symptoms)

Consider discharge with vestibular rehabilitation exercises (Brandt-Daroff)

Arrange follow-up (GP, neurology, ENT or vestibular physiotherapy)

Horizontal nystagmus suggestive of horizontal canal BPPV:

Confirm with the supine roll test and treat with Gufoni manoeuvre (if familiar with this)

Consider discharge with vestibular rehabilitation exercises (Brandt-Daroff)

Arrange follow-up (GP, neurology, ENT or vestibular physiotherapy)

Tips

History alone is insufficient to diagnose BPPV accurately, a positive test is required

The Dix-Hallpike test is considered the gold standard for diagnosing BPPV

The Dix-Hallpike test is only performed on patients without spontaneous nystagmus

Discussion

BPPV is caused by calcium carbonate otoliths in the semi-circular canals of the inner ear. The posterior (90%) and the lateral canals (8%) are most commonly affected by this pathology. Untreated BPPV usually resolve spontaneously over a few weeks.

The Dix-Hallpike test diagnoses BPPV caused by a posterior canal otolith. Typically, after a 5-20 seconds delay, up-beating rotatory nystagmus will be seen, which resolves within one minute. The otolith in the posterior canal BPPV can be repositioned by the Epley manoeuvre, which is effective with one application in 80%.

Horizontal nystagmus on Dix-Hallpike testing suggests the less common horizontal canal BPPV. The Epley manoeuvre will not help to reposition these otoliths. Diagnosis can be confirmed by the supine roll test and repositioning achieved by a Gufoni manoeuvre.

If unfamiliar with the supine roll or Gufoni manoeuvre, an alternative is to discharge the patient with observation, rehabilitation exercises (Brandt-Daroff) and follow-up (GP, ENT, neurology or vestibular physiotherapy). Horizontal canal BPPV usually resolves untreated more quickly than posterior canal BPPV, and observation without repositioning is reasonable.

Vestibular rehabilitation exercises (e.g. Brandt-Daroff) aim to break up rather than reposition the Otolith. They are significantly less effective then repositioning manoeuvres. However, they still have benefit and may be prescribed at discharge, particularly to patients who are not suitable for repositioning.

Medications are not useful for the brief episodes of vertigo associated with BPPV.

Peer review

This guideline has been reviewed and approved by the following:

Emergency Care Institute

Dr Peter Johns, Assistant Professor, Department of Emergency Medicine, University of Ottawa

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical practice guideline: benign paroxysmal positional vertigo (update). Otolaryngol Head Neck Surg. 2017;156(3_suppl):S1-S47. doi:10.1177/0194599816689667

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O’Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

Barton JJS. Benign paroxysmal positional vertigo. In: UpToDate. Waltham (MA): UpToDate. 2018 Dec 17. Available from: https://www.uptodate.com/contents/benign-paroxysmal-positional-vertigo

eTG complete. Melbourne: Therapeutic Guidelines; 2017 Nov. Benign paroxysmal positional vertigo. Available from: https://tgldcdp.tg.org.au/viewTopic?topicfile=benign-paroxysmal-positional-vertigo

Sumner A. The Dix-Hallpike Test. J Physiother. 2012;58(2):131. doi:10.1016/S1836-9553(12)70097-8

You P, Instrum R, Parnes L. Benign paroxysmal positional vertigo. Laryngoscope Investig Otolaryngol. 2018;4(1):116-123. Published 2018 Dec 14. doi:10.1002/lio2.230

Omron R. Peripheral vertigo. Emerg Med Clin North Am. 2019;37(1):11-28. doi:10.1016/j.emc.2018.09.004

Halker RB, Barrs DM, Wellik KE, Wingerchuk DM, Demaerschalk BM. Establishing a diagnosis of benign paroxysmal positional vertigo through the dix-hallpike and side-lying maneuvers: a critically appraised topic. Neurologist. 2008;14(3):201-204. doi:10.1097/NRL.0b013e31816f2820

Dix MR, Hallpike CS. The pathology, symptomatology and diagnosis of certain common disorders of the vestibular system. Ann Otol Rhinol Laryngol. 1952;61(4):987-1016. doi:10.1177/000348945206100403

Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev. 2014;(12):CD003162. Published 2014 Dec 8. doi:10.1002/14651858.CD003162.pub3

Kerber KA, Forman J, Damschroder L, et al. Barriers and facilitators to ED physician use of the test and treatment for BPPV. Neurol Clin Pract. 2017;7(3):214-224. doi:10.1212/CPJ.0000000000000366

NSW Agency for Clinical Innovation. Benign paroxysmal positional vertigo. Sydney: ACI; 2017 Nov. Available from: https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0003/274062/benign-paroxysmal-positional-vertigo-patient-factsheet.pdf

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