Dix-Hallpike Test
Description
The Dix-Hallpike maneuver is a diagnostic tool used to identify benign paroxysmal positional vertigo (BPPV). It helps to provoke the characteristic vertigo and nystagmus associated with BPPV by positioning the patient in a way that stimulates the semicircular canals, particularly the posterior canal. By swiftly moving the patient from a sitting to a head-hanging position, the maneuver stimulates movement of otoconia within the canal, provoking the hallmark vertigo and positional nystagmus seen in BPPV. Its specificity ranges from 75% to 98%, and it is especially effective when performed correctly with attention to head angle and patient relaxation.
History
In 1952, British otologists Margaret Ruth Dix and Charles Skinner Hallpike published a landmark study detailing the pathology, symptoms, and diagnosis of vestibular disorders, notably introducing the diagnostic maneuver now known as the Dix-Hallpike test. This maneuver became the gold standard for diagnosing benign paroxysmal positional vertigo (BPPV), a condition characterized by brief episodes of vertigo triggered by specific head movements. Dix and Hallpike’s work provided a systematic approach to provoke and observe the characteristic nystagmus associated with BPPV, thereby facilitating accurate diagnosis and informing subsequent therapeutic strategies. Their contributions have had a lasting impact on the field of neuro-otology, with the Dix-Hallpike maneuver remaining a cornerstone in the assessment of patients presenting with positional vertigo.
Instructions
The goal of this test is to provoke characteristic vertigo and nystagmus associated with displaced otoconia within the affected semicircular canal. Each side must be tested individually.
Right Ear
- Explain the procedure to the patient and obtain consent.
- Position the patient in long-sitting on the exam table.
- Rotate the patient’s head 45° to the right (toward the side being tested).
- Keep the head to the right, support the head and guide the patient quickly into a supine position with the head hanging ~20–30° below horizontal off the end of the table or over a pillow.
- Observe the patient’s eyes for nystagmus and ask about vertigo symptoms.
- Hold this position at least 30 sec or until symptoms resolve.
- To return, assist the patient back to sitting, maintaining head rotation to the right.
- Monitor for reversal of nystagmus and vertigo during return to sitting and continue to guard patient.
Left Ear
- Explain the procedure to the patient and obtain consent.
- Position the patient in long-sitting on the exam table.
- Rotate the patient’s head 45° to the left (toward the side being tested).
- Keep the head to the left, support the head and guide the patient quickly into a supine position with the head hanging ~20–30° below horizontal off the end of the table or over a pillow.
- Observe the patient’s eyes for nystagmus and ask about vertigo symptoms.
- Hold this position for at least 30 seconds or until symptoms resolve.
- To return, assist the patient back to sitting, maintaining head rotation to the right.
- Monitor for reversal of nystagmus and vertigo during return to sitting and continue to guard patient.
Test Interpretation
A positive Dix-Hallpike test is characterized by a brief latency period followed by a short burst of vertigo accompanied by nystagmus—typically upward and torsional, rotating toward the side being tested. This response generally lasts less than one minute and diminishes in intensity with repeated testing (fatigability). A positive result is confirmed when the patient’s symptoms and observed nystagmus correspond to the side being tested. This finding supports the diagnosis of posterior canal BPPV and informs appropriate treatment planning.
Example of a positive Dix-Hallpike for the right ear:
Related Pathology
- Posterior Canalithiasis
- Posterior Cupulolithiasis
- Anterior Canalithiasis
- Anterior Cupulolithiasis
- Short Arm Posterior Canal
Sources
- Bhattacharyya, Neil, et al. “Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update).” Otolaryngology–Head and Neck Surgery, vol. 156, no. 3_suppl, 2017, pp. S1–S47. https://aaohnsfjournals.onlinelibrary.wiley.com/doi/10.1177/0194599816689667
- von Brevern, M., Bertholon, P., Brandt, T., Fife, T., Imai, T., Nuti, D., & Newman-Toker, D. E. (2015). Benign paroxysmal positional vertigo: Diagnostic criteria. Journal of Vestibular Research, 25(3-4), 105-117. https://pubmed.ncbi.nlm.nih.gov/26756126/
- Fife TD, Iverson DJ, Lempert T, et al. (2008). Practice parameter: therapies for benign paroxysmal positional vertigo. Neurology, 70(22), 2067–2074
- Hilton, M. P., & Pinder, D. K. (2014). The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database of Systematic Reviews, 2014(12), CD003162. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003162.pub3/full
- Kim JS, Zee DS. Benign Paroxysmal Positional Vertigo. N Engl J Med. 2014. https://www.nejm.org/doi/abs/10.1056/NEJMcp1309481