Supine Roll Test

Supine Roll Test (1)

Fundamentals

Definition: The Supine Roll Test is used to identify horizontal canal benign paroxysmal positional vertigo (HC-BPPV), a subtype of BPPV in which dislodged otoconia from the utricle enter the horizontal semicircular canal and provoke symptoms such as vertigo, dizziness, or imbalance by abnormally stimulating the cupula during head movement.

Why we should do this test: Recent research shows HC-BPPV may account for nearly half of all BPPV cases—approximately 46.3% in one large-scale study of 3,975 patients with video-oculography-confirmed BPPV, nearly equal to posterior canal involvement (47.8%). The Clinical Practice Guidelines for BPPV recommend performing both the Dix-Hallpike test and the Supine Roll Test to ensure accurate diagnosis of all BPPV subtypes, including horizontal canal BPPV, which may be missed if only the Dix-Hallpike is performed.

How it’s done: The Supine Roll Test is typically performed with the patient supine and the head in 30 degrees of flexion. Then, the patient’s head is rotated to each side, or, if the patient’s cervical range of motion is limited, it is appropriate to roll their body to get sufficient range. The goal is 90 degrees of rotation both right and left from midline to ensure sufficient likelihood of moving any otoconia that are in a horizontal canal.

What we expect to see: If HC-BPPV is present, the Supine Roll Test is likely to provoke a horizontal nystagmus, either geotropic (toward the ground, ~70% of HC-BPPV cases, which is usually considered to indicate canalithiasis) or apogeotropic (away from the ground, considered to indicate cupulolithiasis). This test can often assist in identifying the affected ear—for canalithiasis with geotropic nystagmus, the side with stronger nystagmus and symptoms is the affected side, and for cupulolithiasis with apogeogropic nystagmus, we will see a weaker nystagmus and symptoms on the affected side.

This test may elicit other types of nystagmus if the patient does not have horizontal canal BPPV. In that case, we can assess for posterior or anterior canal BPPV using other positional tests such as the Dix-Hallpike test. It is also important to consider that positional nystagmus can be present in patients with central or brain-related vestibular issues such as vestibular migraine or cerebellar stroke as well as in patients with a peripheral vestibular hypofunction.

Sensitivity: The Supine Roll Test demonstrates high sensitivity—reported at 89.5% in recent studies—for detecting horizontal canal BPPV. Incorporating the Supine Roll Test alongside the Dix-Hallpike enhances diagnostic accuracy for patients with positional vertigo. 

History

Dr. James A. McClure was among the first to describe horizontal canal benign paroxysmal positional vertigo (HC-BPPV) as a distinct clinical entity. In his 1985 publication, he reported on seven patients who experienced brief vertigo and horizontal nystagmus triggered by head turns or rolling. 

Building upon McClure’s foundational observations, Pagnini, Nuti, and Vannucchi—otolaryngologists at the University of Florence’s Service of Audiology—introduced the Supine Head Yaw Test (SHYT) in 1989. This positional test, now more commonly known as the Supine Roll Test or Pagnini-McClure, provided a standardized bedside method for assessing for HC-BPPV. 

Instructions

The purpose of the Supine Roll Test is to diagnose horizontal canal benign paroxysmal positional vertigo (HC-BPPV) by eliciting horizontal nystagmus and symptoms when the patient’s head is turned to each side, or body roll to each side if cervical range of motion is limited, while the patient is in a supine position. This test distinguishes between canalithiasis and cupulolithiasis based on the direction of the nystagmus and can assist in determining side of involvement.

  1. Begin with the patient lying supine on the exam table and ask them to keep their eyes open throughout this test.
  2. Flex the neck about 30°.
  3. Quickly (if able) rotate the patient’s head to the right, keeping their body in a supine position. It is acceptable to roll the patient onto their side if cervical range of motion is limited.
  4. Observe for nystagmus and note its intensity if present, as well as asking the patient about any symptoms. Maintain this position for 30 seconds.
  5. Return the head (or body if rolled) to center, then quickly (if able) rotate the patient’s head to the left. It is acceptable to roll the patient onto their side if cervical range of motion is limited.
  6. Again, observe for nystagmus and intensity, and inquire about patient symptoms. Maintain this position for 30 seconds.

Test Interpretation

Geotropic (toward the ground) nystagmus on BOTH sides of the Supine Roll Test indicates horizontal canal canalithiasis, with the stronger nystagmus and symptoms typically presenting on the affected side. Apogeotropic (away from the ground) nystagmus on BOTH sides if the Supine Roll Test suggests horizontal canal cupulolithiasis, where the weaker nystagmus typically corresponds to the affected side. For cases where the nystamgus and symptom strength are similar on both sides, clinicians can use the Bow and Lean or Seated Supine Positioning Tests to clarify the affected side. 

Example of an abnormal Supine Roll Test with geotropic nystagmus (canalithiasis), stronger nystagmus and symptoms on the right, consistent with likely right horizontal canalithiasis type BPPV

Related Pathology

  • Horizontal Canalithiasis
  • Horizontal Cupulolithiasis

Sources

  • McClure JA. Horizontal canal BPV. J Otolaryngol. 1985 Feb;14(1):30-5. https://pubmed.ncbi.nlm.nih.gov/4068089/
  • Pagnini P, Nuti D, Vannucchi P. Benign paroxysmal vertigo of the horizontal canal. ORL J Otorhinolaryngol Relat Spec. 1989;51(3):161-70. https://pubmed.ncbi.nlm.nih.gov/2734007/
  • Nuti D, Vannucchi P, Pagnini P. Benign paroxysmal positional vertigo of the horizontal canal: a form of canalolithiasis with variable clinical features. J Vestib Res Equilib Orientat. (1996) 6:173–84. doi: 10.3233/VES-1996-6303 https://pubmed.ncbi.nlm.nih.gov/8744525/
  • Bhandari, R., Bhandari, A., Hsieh, Y.-H., Edlow, J., & Omron, R. (2023). Prevalence of horizontal canal variant in 3,975 patients with benign paroxysmal positional vertigo: A cross-sectional study. Neurology: Clinical Practice, 13(5), e200191 https://pubmed.ncbi.nlm.nih.gov/37664131/
  • Kowalik, Ł., & Krajewski, J. (2024). Comparative Study of Clinical Features of Patients with Different Types of Benign Paroxysmal Positional Vertigo. Journal of Clinical Medicine, 13(16), 4736. https://www.mdpi.com/2077-0383/13/16/4736
  • 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
  • Koju, G., Wang, W., Zhou, Y., & Li, H. (2022). Comparisons of Supine Roll Test and Alternative Positional Tests in HC-BPPV Lateralization. Current Medical Science, 42(3), 613–619. https://pubmed.ncbi.nlm.nih.gov/35678916/
  • Bhandari A, Bhandari R, Kingma H, Strupp M. Modified Interpretations of the Supine Roll Test in Horizontal Canal BPPV Based on Simulations: How the Initial Position of the Debris in the Canal and the Sequence of Testing Affects the Direction of the Nystagmus and the Diagnosis. Front Neurol. 2022 May 31;13:881156. https://pmc.ncbi.nlm.nih.gov/articles/PMC9197467