Dix-

hallpike
Indication of Dix-Hallpike test

• No neurological findings
• No spontaneous nystagmus or gaze nystagmus
• Dizziness and vertigo initiated by head movement
• Short duration
• Not dizzy if still
Positive of posterior BPPV if:

• No spontaneous nystagmus
• One side negative
• Latency (2-30sec) then dizzy
• Peripheral nystagmus (vertigo and rotational)
• Fatigability*
• Lasts 5-60 sec
• Rotatory vertigo towards downwards ear
(affected ear)

Changes with gaze

- Look towards downward ear – more rotational
- Looks towards upward ear – more vertical
Did you know
Typical BPPV history but horizontal nystagmus or no
nystagmus
• This could be horizontal BPPV (10-30%)
• Does not respond to Epley Manoeuvre
• Need different diagnostic test and manoeuvre:
• Supine roll test
• geotrophic vs apogeotrophic)
• Gufoni manoeuvre
• Apogeotrophic – lie on affected ear on side (1
min), and turn 45 degrees and away from ground
(2 min)
• Geographic - lie on good ear on side (1 min) and
turn 45 degrees to ground (2 min
Typical BPPV history but atypical nystagmus
• Consider anterior BPPV – Deep head hang
manoeuvre
• Consider vestibular migraine
• Migraine feature –photophobia,
headache, nausea
• Hx of migraine
• No spontaneous nystagmus
• Persistent nystagmus on dix-hallpike
• Central paroxysmal positional nystagmus -
Refer
Did you know

Supine roll test Gufoni manoeuvre

Deep head hang manoeuvre

HINTS
HINTS + exam
• Peripheral vs central

• Head impulse, nystagmus, test of skew, hearing test

• ONLY on prolonged vertigo + nystagmus

• FAST negative
• No significant headache
Central – ANY OF
• Bidirectional nystagmus

• vertical skew deviation

• Normal head impulse test

Peripheral – ALL OF
• Unidirectional nystagmus

• No vertical skew

• Abnormal head impulse

Clinical case
• 55 y/o male presents with persistent vertigo and nausea for the past
48 hrs
Nystagmus on clinical observation
FAST negative
Criteria met for HINTS exam
1.
A positive dix – hallpike test will show:

A. Horizontal Nystagmus

B. Vertical nystagmus

C. Horizontal and rotational nystagmus

D. Vertical and rotational nystagmus

2.
In classical BPPV:

A. Nystagmus beats towards the affected ear (downward ear)

B. Nystagmus beats away from the affected ear (upward ear)

3.
In vestibular neuritis:

A. Nystagmus beats towards the affected ear

B. Nystagmus beats away from the affected ear

4.
A patient with history of BPPV has a negative dix-hallpike test. What do you
do next?

A. Repeat Dix-Hallpike test after 15min of rest

B. Explain an alternative diagnosis is more likely e.g. vestibular neuritis. Perform HINT
exam to rule out central cause.

C. Diagnose with BPPV and perform Epley Maneuver

D. Turn patients’ head left/right whilst on their back and observe nystagmus
5.

62 year old male attends surgery c/o severe dizziness that started last night. He
denies any recent illness. He has found it difficult to walk in a straight line, which
he attributes to the dizziness. He has vomited once. His head impulse test is normal,
he has a unidirectional nystagmus and skew test is normal. Otherwise, examination
is unremarkable.

A. Menieres disease
B. Acute labyrinthitis
C. Cerebellar stroke
D. Vestibular neuritis
E. BPPV
6.

A 40 year old man presents with a 2 day history of constant vertigo. He is generally
fit and well. His symptoms are associated with some nausea but there is no hearing
loss or tinnitus. He has an abnormal HIT and fine horizontal nystagmus is noted.
There is no skew deviation. Otherwise examination is normal.

A. Vestibular neuritis
B. TIA
C. Cerebellar stroke
D. Menieres disease
E. BPPV
6.
Treasure Hunt on Teams

First person/group to find the following files on Teams wins the chocolate:

1. Vertigo flowchart guideline on Teams

2. Newham microbiology guideline on Teams