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Screenshot 2025-07-02 154930

Fundamentals

The Bow and Lean or Head Pitch Test can be used help identify the affected ear in horizontal canal benign paroxysmal positional vertigo (HC-BPPV). It can be done as a second step after determining likely canalithiasis or cupulolithiasis type (geotropic or apogeotropic) during the Supine Roll Test. This test is reasonable as a supplementary assessment when trying to clarify side of involvement in HC-BPPV, notably when the Supine Roll Test yields symmetrical nystagmus and symptoms.

Lee et al. (2010) demonstrated that the Bow and Lean Test was useful for 35.7% of 126 patients with HC-BPPV (with a mix of canalithiasis and cupulolithiasis cases), because the Supine Roll Test alone was unclear as to which side was the affected side (strength of nystagmus ~equal bilaterally).  
 
More recently, Choo et al. (2020) proposed that vertical nystagmus observed during the Bow and Lean may help detect posterior canal BPPV. Using the Head Pitch Test (Bow and Lean), Martellucci and colleagues found that PC-BPPV could be correctly diagnosed in 75.2% of cases, allowing for less symptom provocation with seated testing, rather than needing to perform a Dix-Hallpike for every patient.

History

Yun-Hoon-Choung (1) (1)

Dr. Hoon Choung

The Bow and Lean Test was first described in 2006 by Dr. Hoon Choung and his team at Ajou University School of Medicine in South Korea. 

Since then, at least 10 studies have utilized the Bow and Lean Test for identification of type and affected side of HC-BPPV and/or PC-BPPV, demonstrating its ongoing potential for improving diagnostic accuracy of challenging BPPV cases.

 

 

Instructions

One purpose of the Bow and Lean Test is to assist in identifying the affected side in HC-BPPV, with a secondary potential of indicating potential PC-BPPV involvement. By observing the direction of nystagmus when the patient’s head is bowed forward and then leaned backward, clinicians may be able to clarify which canal and/or side is affected.

  1. Explain the test to the patient and obtain consent.
  2. Seat the patient upright in a chair or on an examination table and instruct the patient to keep their eyes open throughout test.
  3. Bow:
    1. Instruct the patient to bow their head into 30 degrees of flexion or as far as possible, then instruct the patient bow to their trunk forward 90 degrees or as far as possible.
    2. Hold position for at least 30 seconds and observe for any nystagmus.
  4. Return the head to neutral (upright).
  5. Lean:
    1. Ask the patient to lean their head and/or body as needed to achieve 60 degrees of extension.
    2.  Hold position for at least 30 seconds and observe for any nystagmus.
  6. Return the head to neutral (upright). 

Test Interpretation

For HC-BPPV, in the geotropic (HC canalithaisis) variant, nystagmus usually beats toward the affected ear during the bow position, while in the apogeotropic (HC cupulolithiasis) variant, nystagmus usually beats toward the affected ear during the lean position.

Screenshot 2025-05-30 141332 (1)

Example of an abnormal Bow and Lean Test for left horizontal cupulothiasis BPPV

Related Pathology

The Bow and Lean Test is best done with infrared video goggles due the risk of otherwise missing about 2/3 of abnormal eye movements when testing in room light or with traditional thickened lens Frenzels. See what you’re missing – access a free virtual demo (on-demand or live with a clinician) today.

Sources

  • Choi S, Choi HR, Nahm H, Han K, Shin JE, Kim CH (2018) Utility of the bow and lean test in predicting subtype of benign paroxysmal positional vertigo. Laryngoscope 128(11):2600–2604. https://doi.org/10.1002/lary.27142
  • Choo, O.-S., Kim, H., Jang, J. H., Park, H. Y., & Choung, Y.-H. (2020). Vertical nystagmus in the Bow and Lean Test may indicate hidden posterior semicircular canal benign paroxysmal positional vertigo: Hypothesis of the location of otoconia. Scientific Reports, 10, 6514. https://www.nature.com/articles/s41598-020-63630-3
  • Choung, Y.-H., Shin, Y. R., Kahng, H., Park, K., & Choi, S. J. (2006).’Bow and lean test’ to determine the affected ear of horizontal canal benign paroxysmal positional vertigo. The Laryngoscope, 116(10), 1776–1781. https://onlinelibrary.wiley.com/doi/10.1097/01.mlg.0000231291.44818.be