Otology & Neurotology

00:00Y00 2015, Otology & Neurotology, Inc.

Diagnostic Role of Head-Bending and Lying-Down Tests

in Lateral Canal Benign Paroxysmal Positional Vertigo
Sertac Yetiser and Dilay Ince
Department of Otorhinolaryngology, Anadolu Medical Center, Kocaeli, Turkey

geotropic nystagmus. Approximately 65.6% of patients with apogeotropic and 52% of patients with geotropic nystagmus had nystagmus during LDPT. However, its comparability with HRM was
low. However, treatment plan based on LDPT results alone provided relief of symptoms in additional 12.5% of patients with
apogeotropic and in 2.2% of patients with geotropic nystagmus.
Approximately 63% of patients with apogeotropic and 56% of
patients with geotropic nystagmus were able to tell the worse side.
Nystagmus comparable with HRM during HBT was low and not
diagnostic.
Conclusion: HRM has the greatest diagnostic value of positioning tests in LC-BPPV in this study. LDPT provides some contribution in the diagnosis of LC-BPPV but much less than HRM.
Patients subjective feeling of vertigo was also a useful test. However, HBT was not as sensitive as other measures in uncertain cases.
Key Words: Positional vertigoVVertigoVParoxysmal.

Objectives: To compare the diagnostic value of the head-bending

test (HBT), lying-down positioning test (LDPT) and patients report to identify the affected canal in video-nystagmographically
(VNG) confirmed patients with lateral canal benign paroxysmal
positional vertigo (LC-BPPV).
Study Design: Case series with chart review.
Setting: Head-bending, lying-down positioning and the head-roll
maneuver (HRM) under VNG guidance. The data were collected
in a referral community hospital.
Patients: Seventy-eight patients (32 apogeotropic and 46 geotropic
nystagmus) with LC-BPPV who had been recruited between 2009
and 2013 were enrolled in the study.
Main Outcome Measures: Patients were tested with the HRM
and then were asked about subjectively worse side. Later, they were
subjected to HBT when sitting and the LDPT. The results were
compared and studied with the 1-way ANOVA and chi-square
tests. Statistical significance was set at p G 0.05.
Results: Affected side was identified by HRM in 75% of patients with apogeotropic nystagmus and 95.6% of patients with

Otol Neurotol 00:00Y00, 2015.

Patients with benign paroxysmal positional vertigo of

the lateral canal (LC-BPPV) are diagnosed as having geotropic or apogeotropic bidirectional nystagmus during the
head-roll maneuver (HRM) in the supine position (1Y3).
The type of nystagmus and the severity of vertigo sensation during this test will help diagnose the involved side
when the head is turned (1). An analysis of slow phase
velocity of the recorded nystagmus will also guide to determine the site with more intense nystagmus. A severe and
brief sense of evoked vertigo is generally worse on the

affected side for geotropic type nystagmus and worse on

the healthy side for apogeotropic type nystagmus. Identification of the affected side is very important in selection of
the proper direction to apply the barbeque or liberatory
maneuvers (4Y7). However, this task is not always easy to
accomplish because the evoked nystagmus may be equally
severe on both sides or may be too weak to diagnose.
HRM in the supine position is very helpful in diagnosing
the affected side in LC-BPPV. However, it has been reported
that almost 10% of patients with unilateral LC-BPPV may
have symmetrical nystagmus which makes it difficult to
determine the side of the lesion (8). The examiner then needs
to use additional methods for selection of the affected side,
such as the head-bending test (HBT) when sitting, the lyingdown positioning test (LDPT), or the patients subjective
feeling of vertigo (9). Patients with LC-BPPV frequently
experience a sudden sense of spinning when they bend their
head forward or backward intentionally or unintentionally
such as when falling asleep while reading a newspaper
when sitting, lying down from a sitting position, or getting
out of bed. Those patients may have a brief nystagmus

Address correspondence and reprint requests to Sertac Yetiser, M.D.,

Department of Otorhinolaryngology and Head Neck Surgery, Anadolu
Medical Center, Cumhuriyet mah, 2255 sok, No:3, Gebze 41400, Kocaeli,
Turkey; E-mail: syetiser@yahoo.com, sertac.yetiser@anadolusaglik.org
This study, similar or the same form, has not been submitted to any
other journal for publication or presented in any medical meeting before.
The data were collected and drafted by D. Ince. Data analysis, drafting,
and final approval were completed by S. Yetiser.
None of the authors have any financial, consultant, and institutional
interest for the work or any grant or financial support provided by companies toward the completion of the work. Authors have no conflict of
interest and no disclosures.

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S. YETISER AND D. INCE

associated with these conditions. From this observation,

Nuti and Asprella proposed a test to confirm the diagnosis
of the affected canal in LC-BPPV (10,11). They proposed a
horizontal nystagmus beating to the healthy side in case of
geotropic nystagmus (posterior arm canalolithiasis; otoliths
located away from cupula) and to the affected side in case
of apogeotropic nystagmus (anterior arm canalolithiasis;
otoliths located close to the cupula or cupulolithiasis; otoliths attached to the cupula) when patients are lying down
with their head in a straight head hanging position.
When the head is erect in a sitting patient, an angle of
30 degrees exists between the horizontal plane and the lateral canal in which there will be no gravitational force and no
movement of otoliths inside the canal (10,11). Bending the
head 60 degrees forward brings the lateral canal to 30 degrees with reference to the horizontal plane, and this head
motion causes ampullopetal floating of the otoliths resulting
in a nystagmus toward the affected ear in geotropic nystagmus, or cupular deflection in the opposite direction, toward the unaffected ear in apogeotropic nystagmus (10,11).
Changing the head position to 30 degrees backward will
also change the angle of the lateral canal to an approximately vertical position, and the otoliths will move changing their direction and velocity (10,11). On the other hand,
bringing the patient quickly from the seated position to the
supine position will push the otoliths downward because of
both gravity and deceleration forcing them toward the
utricle if they are free in the canal or toward the ampulla if
they are attached to the cupula. Therefore, this move will
evoke a nystagmus beating toward the healthy side in the

case of geotropic nystagmus or toward the affected side in

the case of apogeotropic nystagmus.
The aim of this study is to compare the diagnostic value
of HBT when sitting, LDPT, and the patients report of
severity of sense of vertigo during HRM in the supine position in patients with LC-BPPV.
MATERIALS AND METHODS
Seventy-eight patients with LC-BPPV who had been recruited
between 2009 and 2013 were enrolled in the study. A verbal and a
signed informed consent were obtained from each patient. The
procedures were in accordance with the ethical standards of the
declaration of Helsinki and of the institutional review board. There
were 36 men and 42 women with age ranging from 14 to 84 years
(42.28 T 11.29). Duration of symptoms was ranging between
2 days and 12 weeks. Main inclusion criteria were normal otoscopic examination, normal hearing threshold, and no problems
other than BPPV. Those with hearing loss, tinnitus, abnormal ear
drum, or other vestibular or neurologic problems and those who
used medication recently which could affect the vestibular system
were excluded. Data were collected in a referral community hospital. All patients were first tested with VNG (Micromedical Technologies, Inc, USA) for spontaneous nystagmus in the seated primary
gaze position before starting the test battery and those with spontaneous nystagmus were excluded from the study. Tests were performed in the order of spontaneous nystagmus, HRM, HBT, and
LDPT. The type, duration, and direction of nystagmus were recorded with an infrared wireless video camera. VNG is done by
goggles with closed camera system (open eyes, closed vision) and
no fixation effect was allowed during the test. Between each test,
the patient rested for 15 to 20 minutes to prevent fatigue.

FIG. 1. View of head-roll maneuver while the patient is lying down. Geotropic or apogeotropic nystagmus (bidirectional, horizontal) is seen
in patients with LC-BPPV (APO, apogeotropic; GEO, geotropic). Dark arrow indicates the direction of the nystagmus.
Otology & Neurotology, Vol. 00, No. 00, 2015

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HEAD-BENDING AND LYING-DOWN TESTS

Presence of brief latency, short duration, and adaptation of
transient nystagmus were always noted to confirm peripheral
type positional nystagmus. Geotropic or apogeotropic nystagmus (bi-directional, horizontal) during HRM while the patient
was lying down was initially documented (Fig. 1). The patients
head was first turned to the right side for 3 minutes and then to
the center position. Later, the head was turned to the left side to
see evoked nystagmus. The affected side was determined according
to the severity of nystagmus as seen on the VNG recording.
Nystagmus of greater velocity was on the affected side in patients
with geotropic nystagmus and on the healthy side in patients with
apogeotropic nystagmus. Patients were defined as undetermined
laterality for geotropic or apogeotropic form if the analysis of the
recorded images shows similar slow phase eye velocity on both
sides. Patients were also asked about how they felt and which side
was worse for the sense of vertigo during HRM.
Later, the patients were subjected to HBT at sitting in 3 different
positions (Fig. 2). First, the head was quickly bent forward by
60 degrees (Position A) while the patient was in the sitting position. Then, the patients head was put in the straight position
(position B). This was actually a movement action from position
A to position B (different from primary gaze position to seek for
spontaneous nystagmus). Finally, the head was bent backward by
30 degrees (position C). This was again a movement action from
position B to position C. The test was performed with VNG, and
each position was held for 5 minutes to obtain sufficient time to
record the evoked nystagmus. The head was grasped and fixed by
the technician at each position. Finally, the patient was asked
to lie down from the sitting position (LDPT) and again evoked
nystagmus was recorded by VNG (Fig. 3). Horizontal positional
nystagmus seen during LDPT was toward the healthy side in
patients with geotropic nystagmus and toward the affected side in

patients with apogeotropic nystagmus. Positional nystagmus during

HBT in patients with geotropic nystagmus was toward the affected
side in position A and toward the healthy side in positions B and C.
However, in patients with apogeotropic nystagmus, it was toward
the healthy side in position A and toward the affected side in
positions B and C.
Patients having nystagmus with asymmetric intensity on both
sides during HRM in the supine position under VNG (the affected
side was clear for geotropic or apogeotropic type nystagmus) and
those having nystagmus with almost equal intensity were determined. Patients having no nystagmus during LDPT and/or HBT
and those having nystagmus during the tests confirming the affected side as detected by HRM were determined. Finally, patients
who were unable to tell the affected side from the severity of sense
of vertigo during the HRM (equal intensity or very mild sense
of spinning), and those who reported asymmetric severity of sense
of vertigo during the HRM were determined. Mean values were
compared for each group. Patients with apogeotropic nystagmus
were treated with Barbeque, Semonts, or Gufoni maneuvers, and
patients with geotropic nystagmus were treated with Barbeque or
Gufoni maneuvers. All patients were controlled within 5 to 7 days
after therapeutic maneuvers. The 1-way ANOVA and chi-square
goodness of fit tests were used for comparative analysis of the
groups. Statistical significance was set at p G 0.05.

RESULTS
Thirty-two patients had apogeotropic, and 46 patients
had geotropic type nystagmus, which were noted in HRM.
Identification of the affected side was possible in 24 of the
32 patients with apogeotropic type nystagmus (75%) by

FIG. 2. View of head bending test at sitting in 3 positions in a patient assuming with healthy left side. A, bending forward; B, straight; C,
bending backward. APO indicates apogeotropic; GEO, geotropic. Dark arrow indicates the direction of the nystagmus.
Otology & Neurotology, Vol. 00, No. 00, 2015

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S. YETISER AND D. INCE

FIG. 3. View of lying down positioning test in a patient assuming with healthy left side (APO, apogeotropic; GEO, geotropic). Dark arrow
indicates the direction of the nystagmus.

HRM (11 in right ear and 13 in left ear). Eighteen patients

with apogeotropic nystagmus were able to tell the worse side
in terms of sense of severity during HRM (18/32; 56%).
Eight patients had nystagmus during HBT position A (8/32;
25%) and 7 patients had nystagmus during HBT position C
(7/32; 21.7%). None of the patients had any nystagmus
during HBT position B. Twenty-one patients had nystagmus during LDPT (21/32; 65.6%), but it was comparable
with the side of the affected canal detected by HRM in 15
patients (15/32; 46.7%), and it was vertical or not comparable with HRM in 6 patients (Fig. 4).
Identification of the affected side was possible in 44 of
the 46 patients with geotropic type nystagmus (95.6%) by
HRM (21 in right ear and 22 in left ear). Twenty-nine
patients were able to tell the worse side in terms of sense
of severity during HRM (29/46; 63%). Thirteen patients
had nystagmus during HBT position A (13/46; 28.3%), and
15 patients had nystagmus during HBT position C (15/46;
32.6%). None of the patients had nystagmus during HBT
position- B. Twenty four patients had nystagmus during
LDPT (24/46; 52%), but it was comparable with the side of
the affected canal detected by HRM in 10 patients (10/46;
21.7%). It was slightly beating up (4 patients) or down
(2 patients) or horizontal but not comparable with HRM
(8 patients) (Fig. 5).
Twenty-three patients with apogeotropic nystagmus
and laterality sign on HRM responded the treatment. The

treatment plan was based on LDPT findings in 6 of 7

patients with equal nystagmus on both sides during HRM
and was effective in 4 after several attempts. Therefore,
the number of patients with cure increased from 71.8%
(23/32) to 84.3% (27/32), when HRM and LDPT are
combined as diagnostic tools, if improvement of symptoms after therapeutic maneuvers are assumed to enhance
the determination of the laterality. Forty-three patients with
geotropic nystagmus and laterality sign on HRM were responded the treatment. Treatment plan was based on the
LDPT findings in 2 patients and was effective in one of
them. Therefore, the number of patients with cure increased
from 93.4% (43/46) to 95.6% (44/46), when combination
of the HRM and LDPT are used as the diagnostic tests.
Comparative analysis of the test results for patients with
geotropic and apogeotropic type nystagmus is presented in
Table 1. Diagnostic value of both the LDPT and patients
reports was better in patients with apogeotropic nystagmus
and also in those with geotropic nystagmus, compared with
the value of HBT. No statistically significant difference
was found when comparing the diagnostic value of HBT in
the 3 positions, LDPT and patients reports between patients with geotropic and those with apogeotropic nystagmus (p 9 0.05). The number of patients who were cured
after treatment and in whom diagnostic evaluation was based
on LDPT alone was statistically significantly better in patients with apogeotropic nystagmus compared with patients

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HEAD-BENDING AND LYING-DOWN TESTS

FIG. 4.

The overall test results of patients with apogeotropic type nystagmus.

having geotropic nystagmus (p = 0.018). However, when

all diagnostic tests were used together, the overall cure rate
in patients with geotropic type nystagmus was statistically
significantly better than patients with apogeotropic type
nystagmus (p = 0.044).
DISCUSSION
Studies related with the diagnostic issues of LC-BPPV
are generally based on HRM only and comparative analysis
with other methods is lacking. Few studies have been published analyzing the diagnostic value of LDPT to determine
the affected canal in patients with LC-BPPV. Han et al. have
analyzed the presence of lying-down nystagmus (toward

FIG. 5.

the healthy ear in geotropic and toward the affected ear in

apogeotropic type) in 152 patients with LC-BPPV and have
observed this nystagmus in 38.2% of patients with documented LC-BPPV (36.4% of the geotropic and 41.5% of
the apogeotropic type) (9). We have found higher incidence
of evoked nystagmus during LDPT in our series (65.6% for
apogeotropic nystagmus and 52% for geotropic nystagmus),
although the number of patients is smaller. However, its
contribution to the diagnosis was less than HRM.
It seems that it is not always possible to evoke the nystagmus with LDPT. This could be related with the density
and the amount of the otoliths or their distance to the cupula
inside the membranous labyrinth to evoke nystagmus or
with the examiner who is unable to do the test adequately

The overall test results of patients with geotropic type nystagmus.

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S. YETISER AND D. INCE

TABLE 1.

Comparative analysis of the test results for patients with geotropic and apogeotropic nystagmus

Tests
Rate of nystagmus seen with HBT-A
Rate of nystagmus seen with HBT-C
Rate of nystagmus seen with LDPT
Patients subjective feeling of more severe side
Patients benefit based on LDPT
Overall cure rate

Geotropic nystagmus (46 patients)

Apogeotropic nystagmus (32 patients)

28.3%
32.6%
52%
63%
2.2%
95.6% (44/46)

25%
21.7%
65.6%
56%
12.5%
84.3% (27/32)

a
a

0.275
0.088
0.655
0.109
0.018
0.044

HRM indicates head-roll maneuver; LDPT, Lying down positioning test; HBT- a, head bending test at position A; HBT- C, head bending test at
position- C.
a
Significant p values.

because the lying down movement should be so quick. We

have also some concern about the order of the tests. We have
done first HBT, then later LDPT. This may cause dispersal
of the debris in some patients. Doing several tests always
in the same order is one of the limitations of this study.
The order of tests would be randomized to reduce the effect
of one test to another one. Several tests may also raise a
question of fatigability and adaptation, although we always
cared about resting patients for 15 to 20 minutes. Another
limitation could be blinding of investigators. Ideally, a person
interpreting a test should be blinded to the results of all the
other tests. Testing and interpretation were made by different
people in this study. However, interpretation of all tests was
made by the same person. Finally, some limitations may exist
to raise a general conclusion for the utility of a clinical test in
a single center study, which needs to be reviewed by a multi
center study.
Choung et al. have reviewed the effect of the so-called
bow and lean test (affected ear was in the same direction
as bowing nystagmus in geotropic nystagmus and the same
direction as leaning nystagmus in apogeotropic nystagmus)
to determine the side of the affected canal in 26 patients
with LC-BPPV. This test, which was actually similar to the
HBT, revealed no nystagmus in 3 patients (11.5%) and was
not comparable with HRM in the supine position in 7 patients (26.9%) (12). Lee et al. have reviewed the lateralizing
value of head bending nystagmus in 54 patients with LCBPPV while sitting (13). Fifteen patients had no headbending nystagmus (27.8%), and it was not comparable
with head turning asymmetric nystagmus in the supine
position in 5 patients. The overall diagnostic value was
63% (34/54).
Identification of the affected side with HRM is generally possible in patients with LC-BPPV in the presence
of nystagmus with asymmetric intensity and the relief of
symptoms after therapeutic maneuver confirms the determination of the laterality. It seems that the cure rate is
high for both geotropic and apogeotropic type LC-BPPV
if the laterality is clearly evident by HRM. Forty-three
of 44 patients with geotropic and 23 of 24 patients with
apogeotropic nystagmus responded well at least to one of
the therapeutic maneuvers. However, HRM indicated the
involved side in 75% of patients with apogeotropic nystagmus and 95.6% of patients with geotropic nystagmus
in this series. Therefore, it is an important measure to
always include other diagnostic signs in the test battery to
increase the rate of identification of the involved side.

Our findings do not support the diagnostic contribution

of HBT in identification of the affected side. It has been
concluded in this study that the diagnostic role of patients
subjective feeling of vertigo, which has not been paid much
attention in previous studies, is reliable and the diagnostic
reliability of patients report and LDPT is statistically more
significant than HBT. However, despite all these diagnostic tests, there were 3 patients with bi-directional geotropic
(1 patient) and apogeotropic nystagmus (2 patients) with
symmetric severity where the affected side remained undiagnosed. Several attempts at therapeutic maneuvers were
required on both sides in these patients, and the cure was
eventually delayed. Although it has been scarcely reported,
this raises a possibility of a bilateral disease.
CONCLUSION
In conclusion, HRM has the greatest diagnostic value of
positioning tests in LC-BPPV in this study. LDPT provides
some contribution in the diagnosis of LC-BPPV but much
less than HRM. LDPT was useful when combined with the
HRM, especially if the patients had symmetric nystagmus
on turning their head to either side. Patients subjective
feeling of vertigo was also a useful test. Therefore, patients
report and LDPT should be included in the test battery of
patients with LC-BPPV. However, HBT was not as sensitive as other measures in uncertain cases in this series.
Acknowledgments: The authors thank all personnel of the
department for their valuable help to the patients. The authors also
thank to Mr. Murat Gul, associate professor, Giresun University,
Department of Statistics (muratagul@yahoo.com) for his review
of the data.

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