Dix-Hallpike Test

15 February 2022
10 mins
Reading

Dix-Hallpike test performed to the right

Female patient sat on examination table with back toward a male clinician. The clinician is turning the patient's head 45 degrees toward the right. Female patient lying on her back on examination table, with head hanging off the edge of the table. Male clinician is turning her head 45 degrees toward the right.
Begin with patient seated, wearing goggles, with head turned 45º to the right. Quickly lie the patient back with head turned 45º and hanging approximately 20º.

 

Dix-Hallpike test performed to the left

Female patient sat on examination table with back toward a male clinician. The clinician is turning the patient's head 45 degrees toward the left. Female patient lying on her back on examination table, with head hanging off the edge of the table. Male clinician is turning her head 45 degrees toward the left.
Begin with patient seated, wearing goggles, with head turned 45º to the left. Quickly lie the patient back with head turned 45º and hanging approximately 20º.

 

Precautions

 

1. Past injuries

Before performing any positioning maneuver, it is important to ask if the patient has current or past injuries of the neck or spine.

 

2. Neurological symptoms

If neurological symptoms occur during the execution of positioning maneuvers, discontinue the procedure immediately and refer for a neurological evaluation. These symptoms might include blurred vision, numbness, weakness of the arms or legs or confusion.

 

3. Otoconia displacement

It is important to remember that the consistency of fluid inside the vestibular system is relatively viscous; therefore, you should allow sufficient time within each of the Dix-Hallpike maneuvers for the otoconia to achieve maximum displacement. This condition may also be responsible for a delayed onset of nystagmus.

 

4. Consider using VNG

It is most helpful to utilize Frenzel lenses or VNG while performing the Dix-Hallpike test. This reduces the ability of the patient to fixate during the procedure in an attempt to reduce the nystagmus This will also allow the examiner to see even very slight torsional nystagmus.

 

5. Postural support

It is not unusual for the patient to lose postural control at the completion of the procedure due to the otoconia briskly falling within the cupula. It is vital that the examiner is in a stance that will provide the patient with postural support in this situation.

 

6. Affected ear

It is common for the patient to tell you during the intake interview which ear is affected and to describe accurately the symptoms of BPPV. Use this information to determine which ear is likely the affected ear. ALWAYS test both ears - even if the patient complains of only one side being affected.

 

Dix-Hallpike test procedure

  1. Begin with the patient sitting length-wise on the examination table.
  2. Place the Frenzel/VNG goggles on the patient.
  3. Have the patient turn his head to a 45º angle toward the side that you suspect to be affected.
  4. While maintaining the 45º head position, guide the patient in a continuous motion from sitting to lying with the head hanging off the table at approximately 20º. It is imperative to provide cervical support during this portion of the procedure.
  5. Hold this position for 30-60 seconds or until nystagmus has subsided.
  6. Guide the patient back into a sitting position.
  7. Allow 30-60 seconds in the sitting position to allow for the patient to recover.
  8. Have the patient turn his head 90º toward the unaffected side, so that the head is at a 45º angle toward the unaffected side.
  9. While maintaining the 45º head position, guide the patient in a continuous motion from sitting to lying with the head hanging off the table at approximately 20º. It is imperative to provide cervical support during this portion of the procedure.
  10. Hold this position for 30-60 seconds or until nystagmus has subsided.
  11. Guide the patient back into a sitting position.
  12. Maintain postural support until the patient is physically stable.

 

References

  • Dix MR, Hallpike Pathology, symptoms and diagnosis of certain disorders of the vestibular system. Proc R Soc Med. 1952;45:341-354
  • Hughes CA, Proctor Benign paroxysmal positional vertigo. Laryngoscope. 1997;107:607-613.

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Interacoustics

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