Performing positional testing (VNG)

So now that we finished the Dix Hallpike, we're going to do the positional tests. And you'll notice that the patient is lying at an incline, a 30-degree incline. This is the same position that she would be in for the caloric testing, that's going to come later. So that's why she's in this position. In here, we're going to try to put her head in the center, and then we're going to put her head to the right and to the left. And we may even have to roll around her side.

Instructions

So we're going to see if we can provoke nystagmus in a specific position. Okay, so I'm going to get started to put the cover on, because this test is also done with the eyes open in the dark. And then her first position in the position test is supine, 30 degrees, head center. So she's just going to be sitting like this.

And I'm just going to use my remote control to start the software. And then the test defaults for 30 seconds. If there isn't any positional nystagmus happening, 30 seconds is a long time. So it's not like it's going to provoke a little bit later on. So after about 15 seconds, and if I don't see anything, I'm just going to continue on to the next head position.

Test procedure

So I'm going to turn her head. I'm just going to hit next and I'm going to turn her head to the right. And then we're going to do the same thing. So now 15 seconds or so. And if I don't see anything, I'm going to stop the test. If I did see nystagmus, I would continue on for that next 15 seconds. She doesn't have any nystagmus in this position, but we're going to kind of pretend as if she did.

And if she did have nystagmus, then we would want to stop this test and open up her body to the right sub test. So here we go. So we selected the body to the right. And so now my instructions to her. This is a little awkward for the patient, so you really want to kind of help them through and make them feel comfortable doing this. So what I'm going to ask her to do is to tuck her right arm underneath, and she's gonna come up on her right leg and her right arm. And then I'll usually hold the head here. Now holding her head into position.

She's laying down on the side, but I'm kind of here for support just to let her know that I'm here. Remember, she's in the dark, and now she's laying on her side, she might even be dizzy. So she might be a little bit disoriented. So I'm just here for moral support, kind of bracing her head for her. And then we'll just let it run its course it only has five more seconds. And then I'm going to bring her back to center and then we're gonna go to the left.

Okay, so now it's coming back to the center. I'm gonna let her relax for a second. Okay. All right. And then first thing we're going to do is roll her head to the left now. So just roll your head to the left. And then we'll start the test. And again, looking at the screen to see if there's any position-evoked nystagmus with her head to the left. I don't see any, so I can go ahead and stop. Again. If there was nystagmus here, I could roll her to the left side like we did to the right side. But since there isn't any nystagmus, we can just be done with the test and bring her back to the center.

And now she's finished.

Abnormal positional test

This is an example of an abnormal positional test. And we can see here that when the patient was just supine, so lying in the chair, that 30-degree angle, they didn't have any noticeable nystagmus. When I rolled her head to the right, we see three degrees of nystagmus. So there's some nystagmus there, it's not real big, it's not significant.

When rolling the head to the left, you can see that the nystagmus was going all the way up to 16 degrees per second. So this is a really nice definitive test for a left lateral canal BPPV because the nystagmus was is in both directions, but stronger when the head was rolled to the left.