Straight Head Hanging Test

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Fundamentals 

The straight head hanging test or supine head hanging test (SHH) is a positional test used to assess for benign paroxysmal positional vertigo (BPPV), particularly involving the anterior canal and, in some cases, atypical variants of posterior canal BPPV. Collectively, the anterior and posterior canals are defined as vertical canals in the vestibular system given their orientation in space. The test is performed by transitioning the patient from a seated to supine position with the head extended approximately 30 degrees. This position aligns the vertical canals with gravity, facilitating the movement of any otoconia that may provoke nystagmus.

The possible presentations are: 
(1) With anterior canal BPPV (AC-BPPV), the expected nystagmus in the SHH would be either straight downbeating or downbeat with a torsional component toward the affected side.  
 
(2) With long arm posterior canalithiasis, the expected nystagmus in the SHH would be upbeating torsional nystagmus toward the affected side.
 
(3) With short arm posterior canalithiasis, the nystagmus presentation in the SHH can vary depending on the exact location of the otoconia in the short arm. The nystagmus could straight downbeating, absent, downbeating torsional away from the affected side, or upbeating torsional toward the affected side.
 
In a multicenter retrospective study of 13 possible AC-BPPV cases by Porwal et al. (2021), the SHH was more useful than using only the Dix-Hallpike test.  The best option for anterior canal cases (and likely also true for short arm posterior canal cases) seems to include performing both the SHH and bilateral Dix-Hallpike tests for the most complete information.

History

Dr. Darío Andrés Yacovino
Dr. Darío Andrés Yacovino
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Dr. Timothy C. Hain

The SHH test was first described by Yacovino, Hain, and Gualtieri in 2009 as they worked to better understand AC-BPPV. 

Subsequent three-dimensional simulations by Bhandari et al. (2021) have confirmed the biomechanical basis of the test, demonstrating its theoretical effectiveness in moving otoconia within the anterior canal. More recent patient studies also show its applicability to likely short arm posterior canal BPPV cases.

Instructions

The goal of the SHH is to assess for nystagmus and symptoms that may be consistent with BPPV while the head is at midline and extended at least 30 degrees. 

 

  1. Explain the test to the patient and obtain consent.
  2. Sit the patient upright on the exam table in long sitting.
  3. Support the patient’s head and upper body and guide them quickly (if possible) into a supine position.
  4. Extend the head 30 deg (pillow under the shoulders or have the head hanging off of the edge of the table while supported in the hands of the clinician).
  5. Observe eyes for nystagmus for 60 seconds and ask about symptoms.
  6. Return the patient to sitting and continue to guard the patient.

Test Interpretation

A nystagmus consistent with possible AC-BPPV in the SHH would be nystagmus that is straight downbeating or downbeating with slight torsion toward the affected side. For AC-BPPV canalithiasis type, the nystagmus usually has a crescendo and decrescendo and should last <60 seconds. If not, we can suspect either an atypical BPPV such as short arm posterior canal or a central cause of nystagmus. 

While not specifically designed to test the posterior canal for BPPV, you may alternatively provoke posterior canal BPPV with the SHH. 

(1) With long arm posterior canalithiasis, the expected nystagmus in the SHH would be upbeating torsional nystagmus toward the affected side.

(2) With short arm posterior canalithiasis, the nystagmus presentation in the SHH can vary depending on the exact location of the otoconia in the short arm. The nystagmus could straight downbeating, absent, downbeating torsional away from the affected side, or upbeating torsional toward the affected side.

Related Pathology

  • Posterior Canalithiasis
  • Posterior Cupulolithiasis
  • Anterior Canalithiasis
  • Anterior Cupulothiasis
  • Short Arm Posterior Canal

Sources

  • Bhandari A, Bhandari R, Kingma H, Strupp M. Diagnostic and Therapeutic Maneuvers for Anterior Canal BPPV Canalithiasis: Three-Dimensional Simulations. Front Neurol. 2021 Sep 24;12:740599. doi: 10.3389/fneur.2021.740599. PMID: 34630309; PMCID: PMC8497794. https://pmc.ncbi.nlm.nih.gov/articles/PMC8497794/
  • Bhandari R, Bhandari A, Hsieh YH, Edlow J, Omron R. Prevalence of Horizontal Canal Variant in 3,975 Patients With Benign Paroxysmal Positional Vertigo: A Cross-sectional Study. Neurol Clin Pract. 2023 Oct;13(5):e200191. doi: 10.1212/CPJ.0000000000200191. Epub 2023 Aug 23. PMID: 37664131; PMCID: PMC10473829. https://pmc.ncbi.nlm.nih.gov/articles/PMC10473829/#R3
  • Califano L, Salafia F, Mazzone S, Melillo MG, Califano M. Anterior canal BPPV and apogeotropic posterior canal BPPV: two rare forms of vertical canalolithiasis. Acta Otorhinolaryngol Ital. 2014 Jun;34(3):189-97. PMID: 24882928; PMCID: PMC4035840. https://pmc.ncbi.nlm.nih.gov/articles/PMC4035840/
  • Helminski JO. Atypical PC-BPPV – Cupulolithiasis and Short-Arm Canalithiasis: A Retrospective Observational Study. J Neurol Phys Ther. 2025 Jan 1;49(1):51-61. doi: 10.1097/NPT.0000000000000494. Epub 2024 Oct 16. PMID: 39656163; PMCID: PMC11594558. https://pmc.ncbi.nlm.nih.gov/articles/PMC11594558/
  • Kim JS, Zee DS. Benign paroxysmal positional vertigo. N Engl J Med. 2014;370(12):1138-1147. doi: 10.1056/NEJMcp1309481 https://www.nejm.org/doi/full/10.1056/NEJMcp1309481
  • Ling X, Kim HJ, Lee JH, Choi JY, Yang X, Kim JS. Diagnostic Value of Straight Head Hanging in Posterior Canal Benign Paroxysmal Positional Vertigo. J Clin Neurol. 2021 Oct;17(4):558-562. doi: 10.3988/jcn.2021.17.4.558. PMID: 34595864; PMCID: PMC8490902. https://pmc.ncbi.nlm.nih.gov/articles/PMC8490902/#B15
  • Porwal P, V R A, Pawar V, Dorasala S, Bijlani A, Nair P, Nayar R. Clinical and VNG features in anterior canal benign paroxysmal positional vertigo—an analysis of 13 cases. Front Neurol. 2021;12:618269. doi:10.3389/fneur.2021.618269 https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2021.618269/full
  • Yacovino DA, Hain TC, Gualtieri F. New therapeutic maneuver for anterior canal benign paroxysmal positional vertigo. J Neurol. 2009 Nov;256(11):1851-5. doi: 10.1007/s00415-009-5208-1. Epub 2009 Jun 18. PMID: 19536580. https://pubmed.ncbi.nlm.nih.gov/19536580/