Head roll to the right	Head roll to the left

Helpful hints

1. Past injuries

Before performing any form of positioning maneuver, it is important to ascertain whether 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 positions 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 when performing positional maneuvers. 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 horizontal nystagmus.

5. Affected ear

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

6. Severe dizziness

Patients are often very sensitive to horizontal canal BPPV, resulting in severe dizziness and If the patient reacts violently during the roll test, immediately turn the patient to the opposite side and perform a Lempert 360º roll.

Procedure

1. Begin with the patient sitting length-wise on the examination table.
2. Place the Frenzel/VNG goggles on the patient.
3. Guide the patient into a supine A slight elevation of the head (approximately 20º) is helpful.
4. Have the patient turn his head 90º to either side. If the patient does not have enough cervical flexibility to provide maximum otoconia displacement, have the patient roll onto his shoulder.
5. Carefully observe whether nystagmus is present. Make note of the severity and the direction of the nystagmus.
6. Guide the patient back into a neutral, supine position.
7. Turn the patient’s head 90º to the opposite side (roll onto the shoulder if necessary).
8. Again observe whether there is nystagmus; if so, make note of the severity and direction of the nystagmus.
9. Guide the patient back into a neutral, supine position.

Results

1. Geotropic nystagmus

Nystagmus is worse on the affected side and beats toward the ground. Best treated with the Lempert 360º roll. Acceptable alternative treatments are the Gufoni maneuver and forced prolonged positioning.

2. Apogeotropic nystagmus

Nystagmus is worse on the unaffected side and beats away from the ground. Best treated by first converting the nystagmus to geotropic and then performing the Lempert 360º roll. Acceptable alternative treatments are head thrust, Gufoni maneuver, Vannucchi-Asprella and forced prolonged positioning.

References

• Korres S and others. Occurrence of semicircular canal involvement in Benign Paroxysmal Positional Otol Neurotol 23:926-932, 2002

• Gans RE: Evaluating the Dizzy Patient: Establishing Clinical Pathways. Hearing Review 1999; 6 (6): 45-47

• Fife TD. Recognition and management of horizontal canal benign positional vertigo. Am J Otol 1998;19:345-351