11/13/24, 7\:01 PM Guide | Dix-Hallpike test & Epley manoeuvre

Dix-Hallpike test & Epley manoeuvre

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Background

The Dix-Hallpike test is a diagnostic manoeuvre used to identify benign paroxysmal positional vertigo (BPPV) and con
a
The Epley manoeuvre is used to treat BPPV (usually of the posterior canal) once it has been diagnosed by the previously
mentioned Dix-Hallpike test.
This article provides a step-by-step guide to performing both the Dix-Hallpike test and the Epley manoeuvre in an OSCE
setting.

Indications for the Dix-Hallpike test

The Dix-Hallpike manoeuvre is indicated for patients with paroxysmal vertigo in whom BPPV is considered in the di
diagnosis. These patients experience vertigo in brief episodes lasting less than one minute with changes of head position and
return to normal between episodes. Light-headedness or a sensation of nausea might last longer than one minute, however, if
the sensation of movement persists for more than one minute alternative diagnoses should be considered.
¹

Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
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Ask if the patient has noticed whether turning to one particular side seems to trigger the symptoms, which may provide an
indication of the a
Brie
t o h e l p d i a g n o s e a n d p o s s i b l y t r e a t t h e d i z z y e p i s o d e s y o u' v e b e e n e x p e r i e n c i n g. T h e
s i t t i n g t o a l y i n g p o s i t i o n b r i s k l y o n t h e e x a m i n a t i o n c o u c h . T h e s e c o n d s t a g e w i l l i n v o l v e m e h o l d i n g y o u r h e a d w h i l s t a s k i n g
y o u t o r o l l o n t o y o u r s i d e a n d t h e n t o s i t u p r i g h t .
"
Check if the patient has any back or neck problems that would contraindicate performing the assessments\:
" D o y o u h a v e a n y n e c k o r b a c k p r o b l e m s ?"
" D o y o u h a v e a n y p a i n a n y w h e r e c u r r e n t l y ?"
Check the patient has someone who can help them get home safely, as they may be dizzy after the procedure.
Gain consent to proceed with the examination.
Ask the patient to sit on the examination couch.
Contraindications
It's important to have an awareness of absolute and relative contraindications to performing the Dix-Hallpike and Epley
²
maneuvres.
Absolute contraindications\:
Fractured odontoid peg
Recent cervical spine fracture
Atlanto-axial subluxation
Cervical disc prolapse
Vertebrobasilar insu
Recent neck trauma
Relative contraindications\:
Carotid sinus syncope
Severe neck or back pain
Recent stroke
Cardiac bypass surgery within the last 3 months
Rheumatoid arthritis a
Recent neck surgery
Cervical myelopathy
Severe orthopnea

Dix-Hallpike test

When performing the Dix-Hallpike test, make sure to warn the patient in advance of each step, so that they know what to
expect\:
1. Ask the patient to sit upright on the examination couch.
2. Adjust the patient's position so that when supine, their head will hang over the edge of the bed, allowing for head extension
below the horizontal plane.
3. Position yourself standing behind the patient.
4. Turn the patient's head 45º to one side (i.e. left or right) - if the patient has suggested turning their head to a particular side
appears to trigger the symptoms, you should try this side
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5. Whilst supporting the neck, move the patient from their sitting position to a supine position in one brisk smooth motion,
ensuring their head hangs over the bed 30º below the horizontal plane. Ask the patient to keep their eyes open throughout this
process.
6. Inspect the patient's eyes carefully for evidence of nystagmus for at least 30 seconds.
7. If no nystagmus is observed on the assessment of the
you should carefully help the patient sit back up.
8. In the case of a negative Dix-Hallpike test on the
turning the patient's head in the opposite direction during step 4. If no nystagmus is observed on assessment of the other side,
the patient should be sat up and an alternative diagnosis to BPPV should be considered.
9. If the test is positive, the characteristics of the patient's nystagmus should be observed (see details below) and you should
then consider performing the Epley manoeuvre.
Position the patient on the examination couch

Positive test

If the test is positive, the patient will complain of vertigo and you should be able to observe nystagmus directly.
Be aware that patients often feel very dizzy and nauseated when vertigo is triggered.
Asking the patient to
Nystagmus
You should note the following characteristics of the nystagmus\:
Duration
Direction
Latency
The typical
A 2-20 second latent period followed by the onset of torsional (rotary) or horizontal nystagmus. Rotary nystagmus is the most
common type and suggests the involvement of the posterior semicircular canal. Horizontal nystagmus suggests the
involvement of the lateral semicircular canal.
Nystagmus typically lasts between 20-40 seconds.
The nystagmus typically wanes with repeated Dix-Hallpike tests.
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Di
further assessment, where special cameras are used to di

Epley manoeuvre

When performing the Epley manoeuvre, each position should be maintained until full resolution of symptoms and nystagmus
has been achieved for at least 30 seconds\:
1. The Epley manoeuvre typically follows on from a positive Dix-Hallpike test, so we will assume the patient is still positioned
lying
2. Turn the patient's head 90º to the contralateral side, approximately 45º past the midline, still maintaining neck extension over
the bed. Keep the patient in this position for 30 seconds.
3. Whilst maintaining the position of the patient's head, ask the patient to roll onto their shoulder (on the side their head is
currently turned towards).
4. Once the patient is on their side, rotate the patient's head so that they are looking directly towards the
position for 30 seconds to a minute.
5. Sit the patient up sideways, whilst maintaining head rotation.
6. Once the patient is sitting upright, the head can be re-aligned to the midline and the neck can be
facing downwards (chin to chest). Maintain this position for 30 seconds.
The entire procedure can be repeated 2-3 times if needed, however, this will depend on whether the patient is able to tolerate
further manoeuvres (as they often precipitate vertigo).
Move onto Epley's manoeuvre from the

To complete the examination...

Explain to the patient that the examination is now
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Summarise your
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Example summary
" T o d a y I e x a m i n e d M r S m i t h , a 2 5- y e a r-o l d m a l e. t h e r e w e r e n o a b n o r m a l i t i e s n o t e d o n i n s p e c t i o n.
"
O n g e n e r a l i n s p e c t i o n , t h e p a t i e n t a p p e a r e d c o m f o r t a b l e a t r e s t a n d
" T h e D i x-H a l l p i k e t e s t o n t h e l e f t e l i c i t e d v e r t i g o a n d t o r s i o n a l n y s t a g m u s w a s o b s e r v e d . A s a r e s u l t , E p l e y m a n o e u v r e , w h i c h r e s u l t e d i n t h e r e s o l u t i o n o f s y m p t o m s o n t h e
"
I p e r f o r m e d t h e
" I n s u m m a r y, t h e s e
"
" F o r c o m p l e t e n e s s , I w o u l d l i k e t o p e r f o r m t h e f o l l o w i n g f u r t h e r a s s e s s m e n t s a n d i n v e s t i g a t i o n s.
"

Further assessments and investigations

Hearing assessment and otoscopy\: if considering inner ear pathology.
Cerebellar examination\: if considering central causes of vertigo.

References

1. Jonathan D. Talmud; Peter F. Edemekong. Dix-Hallpike Maneuver. Published on April 10th 2019. Available from\: [LINK].
2. British Society of Audiology. Recommended Procedure for Hallpike Manoeuvre. Published in 2014. Available from\: [LINK].
Source\: geekymedics.com
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