Determining the Affected Ear in Benign Paroxysmal Positional Vertigo (BPPV)

Diagnostic Maneuvers

The American Academy of Otolaryngology-Head and Neck Surgery recommends the Dix-Hallpike maneuver for diagnosing posterior canal BPPV, which involves quickly moving the patient from sitting to a supine position with the head turned 45 degrees to one side and extended about 20 degrees below horizontal, to identify the affected ear based on the resulting nystagmus pattern 1, 2, 3, 4
The supine roll test is used for lateral canal BPPV, where the patient is positioned supine with head neutral, then quickly rotated 90 degrees to each side, to determine the affected ear based on the direction and intensity of the induced nystagmus 1, 2, 5

In posterior canal BPPV, the affected ear is identified by the presence of characteristic torsional upbeating nystagmus with a brief latency period, a crescendo-decrescendo pattern, and resolution within 60 seconds when the affected ear is positioned downward during the Dix-Hallpike test 3, 4
In lateral canal BPPV, the geotropic type is characterized by nystagmus beating toward the ground on the affected side, while the apogeotropic type is characterized by nystagmus beating away from the ground on the affected side 1, 2, 5

The lying-down nystagmus test, head pitch test, and bow and lean test can be used as additional methods to determine the affected ear in lateral canal BPPV when standard testing is inconclusive 1, 2, 6, 7

Exercise caution when performing these tests in patients with cervical stenosis, limited cervical range of motion, severe kyphoscoliosis, cervical radiculopathies, ankylosing spondylitis, spinal cord injuries, or morbid obesity 2, 5, 6
The diagnostic accuracy of the Dix-Hallpike maneuver varies, with a sensitivity of 82% and specificity of 71% among specialists, and a positive predictive value of 83% but lower negative predictive value of 52% in primary care settings 3, 4