The Dix–Hallpike or Nylén–Bárány test is a diagnostic maneuver from the group of rotation tests used to identify

benign paroxysmal positional vertigo Benign paroxysmal positional vertigo (BPPV) is a disorder arising from a problem in the inner ear. Symptoms are repeated, brief periods of vertigo with movement, characterized by a spinning sensation upon changes in the position of the head. * ...

(BPPV).

Procedure

When performing the Dix–Hallpike test, patients are lowered quickly to a

supine position The supine position () means lying horizontally, with the face and torso facing up, as opposed to the prone position, which is face down. When used in surgical procedures, it grants access to the peritoneal, thoracic, and pericardium, pericardial ...

(lying horizontally with the face and torso facing up) with the neck extended 30 degrees below horizontal by the clinician performing the maneuver. The Dix–Hallpike and the side-lying testing position have yielded similar results. As such, the side-lying position can be used if the Dix–Hallpike cannot be performed easily. Steps: The examiner looks for

nystagmus Nystagmus is a condition of involuntary (or voluntary, in some cases) Eye movement (sensory), eye movement. People can be born with it but more commonly acquire it in infancy or later in life. In many cases it may result in visual impairment, re ...

(usually accompanied by

vertigo Vertigo is a condition in which a person has the sensation that they are moving, or that objects around them are moving, when they are not. Often it feels like a spinning or swaying movement. It may be associated with nausea, vomiting, perspira ...

). In BPPV, the nystagmus typically occurs in A or B only, and is torsional—the fast phase beating toward the lower ear. Its onset is usually delayed a few seconds, and it lasts 10–20 seconds. As the patient is returned to the upright position, transient nystagmus may occur in the opposite direction. Both nystagmus and vertigo typically decrease on repeat testing.

Interpretation

Positive test result

A positive test is indicated by patient report of a reproduction of vertigo and clinician observation of nystagmus (involuntary eye movement). For some patients, this maneuver may be contraindicated, and a modification may be needed that also targets the

posterior semicircular canal The semicircular canals are three semicircular interconnected tubes located in the innermost part of each ear, the inner ear. The three canals are the lateral, anterior and posterior semicircular canals. They are the part of the bony labyrinth, ...

. Such patients include those who are too anxious about eliciting the uncomfortable symptoms of vertigo, and those who may not have the range of motion necessary to comfortably be in a supine position. The modification involves the patient moving from a seated position to side-lying ''without'' their head extending off the examination table, such as with Dix–Hallpike. The head is rotated 45 degrees away from the side being tested, and the eyes are examined for nystagmus.

Negative test

If the test is negative, it makes benign positional vertigo a less likely diagnosis and

central nervous system The central nervous system (CNS) is the part of the nervous system consisting primarily of the brain, spinal cord and retina. The CNS is so named because the brain integrates the received information and coordinates and influences the activity o ...

involvement should be considered.

Advantages

Although there are alternative methods to administering the test, Cohen proposes advantages to the classic maneuver. The test can be easily administered by a single examiner, which prevents the need for external aid. Due to the position of the subject and the examiner, nystagmus, if present, can be observed directly by the examiner.

Limitations

The negative predictive value of this test is not 100%. Some patients with a history of BPPV will not have a positive test result. The estimated sensitivity is 79%, along with an estimated specificity of 75%. The test may need to be performed more than once, as it is not always easy to demonstrate observable nystagmus that is typical of BPPV. Also, the test results can be affected by the speed with which the maneuver is conducted and the plane of the

occiput The occipital bone () is a cranial dermal bone and the main bone of the occiput (back and lower part of the skull). It is trapezoidal in shape and curved on itself like a shallow dish. The occipital bone lies over the occipital lobes of the ...

. There are several disadvantages proposed by Cohen for the classic maneuver. Patients may be too tense, for fear of producing vertigo symptoms, which can prevent the necessary brisk passive movements for the test. A subject must have adequate

cervical spine In tetrapods, cervical vertebrae (: vertebra) are the vertebrae of the neck, immediately below the skull. Truncal vertebrae (divided into thoracic and lumbar vertebrae in mammals) lie caudal (toward the tail) of cervical vertebrae. In sauro ...

range of motion Range of motion (or ROM) is the linear or angular distance that a moving object may normally travel while properly attached to another. In biomechanics and strength training, ROM refers to the angular distance and direction a joint can move be ...

to allow neck extension, as well as trunk and hip range of motion to lie supine. From the previous point, the use of this maneuver can be limited by musculoskeletal and obesity issues in a subject.

Precautions and contraindications

In rare cases a patient may be unable or unwilling to participate in the Dix–Hallpike test due to physical limitations. In these circumstances the side-lying test or other alternative tests may be used. Precautions *The Dix–Hallpike maneuver places a degree of stress on the patient's lower back; therefore, a cautious approach must be taken with patients who are suffering from back pain. *Severe respiratory or cardiac problems may not allow a patient to tolerate the maneuver. For example a patient with orthopnoea may not be able to participate in the procedure, as the patient may have troubling breathing when lying down. Absolute

contraindications In medicine, a contraindication is a condition (a situation or factor) that serves as a reason not to take a certain medical treatment due to the harm that it would cause the patient. Contraindication is the opposite of indication, which is a rea ...

#Neck surgery #Severe

rheumatoid arthritis Rheumatoid arthritis (RA) is a long-term autoimmune disorder that primarily affects synovial joint, joints. It typically results in warm, swollen, and painful joints. Pain and stiffness often worsen following rest. Most commonly, the wrist and h ...

# Atlantoaxial and occipitoatlantal instability #

Aplasia Aplasia (; from Greek ''a'', "not", "no" + ''plasis'', "formation") is a birth defect where an organ or tissue is wholly or largely absent. It is caused by a defect in a developmental process. Aplastic anemia is the failure of the body to produ ...

odontoid process In anatomy, the axis (from Latin ''axis'', "axle") is the second cervical vertebra (C2) of the spine, immediately inferior to the atlas, upon which the head rests. The spinal cord passes through the axis. The defining feature of the axis is its ...

#Cervical

myelopathy Myelopathy describes any neurologic deficit related to the spinal cord. When due to trauma, myelopathy is known as (acute) spinal cord injury. When inflammatory, it is known as myelitis. Disease that is vascular in nature is known as vascular ...

#Cervical

radiculopathy Radiculopathy (; ), also commonly referred to as pinched nerve, refers to a set of conditions in which one or more nerves are affected and do not work properly (a neuropathy). Radiculopathy can result in pain (radicular pain), weakness, altered se ...

#Carotid sinus syncope #Vascular dissection syndromes

Footnotes

External links

Overview and diagrams at dizziness-and-balance.com

video of Dix–Hallpike test
{{DEFAULTSORT:Dix-Hallpike test Medical tests Ear procedures