Diagnosis

Diagnosis is done by observing nystagmus

during maneuvers
Accurate observations of the nystagmus
requires removing the fixated otolith
PC-BPPV
Using the Dix-Hallpike Maneuver in the direction
of the involved ear canal (gold standard)
Mechanism:
Otolithic debris away from the cupula
endolymph hidrodynamic drag stimulation of the
cupula
Excitation of the posterior canal activation of
ipsilateral superior oblique and contralateral inferior
rectus muscles upbeating and torsional nystagmus
Special precautious:
History of neck surgery
Cervical radiculopathy
Vascular dissection syndrome
The side-lying test may be used as an
alternative
Dix-Hallpike maneuver
A. Seating the patient upright

B. Head is turned 45 degree in the direction of the involved ear (B: right ear in this figure)

C. The patient is then moved from the sitting to the supine position, ending with the head
hanging at 20 degree off the end of table

Side-lying Test
A. Seating the patient upright
B. Head turned 45 degree angle away from involved ear
C. Patient lies on the side of the involved ear
HC-BPPV
Supine-roll test (Pagnini McClure maneuver)
Nystagmus would appear:
Geotropic: beat toward the ground (canalolithiasis)
Apogeotropic: beat toward the ceiling (cupulolithiasis)
Although difficult, its important to determine its
lateralization although difficult
Nystagmus appears stronger when head is turned
toward the affected ear
Other than the Pagnini, lying down nystagmus
(LDN) or head-bending nystagmus (HBN) could
be used as an alternative
Lateralization of HC-BPPV
Lateralization of the lesion side of HC-BPPV
Geotropic Nystagmus Apogeotropic nystagmus
Intensity of nystagmus (Ewald's second law) Stronger side Weaker side
Lying-down nystagmus (sitting to supine position) Usually contralesional Usually ipsilesional
Head-bending nystagmus (bending the head forward) Usually ipsilesional Usually contralesional
Reversal of initial nystagmus Possibly occurs ipsilesionally Uncommon
Null point (during head turning, 10-20 degree) Uncommon, but laterality is uncertain Usually present on lesion side
AC-BPPV
SHH as well as Dix-Hallpike maneuver on
either side may evoke downbeat nystagmus
with an ipsitorsional (upper poles of the eyes
beating toward involved ear) component.
The torsional nystagmus may not be as
apparent as PC-BPPV
Mixed-canal type of BPPV
BPPV may involve multiple semicircular canals
PC- and HC- are the most common
combination
MC BPPV frequently involves canals on the
same side
Trauma may increase the risk of MC BPPV
Differential Diagnosis
Posterior circulation stroke may mimic BPPV
Lesions involving cerebellum
Central paroxysmal positional vertigo as an
infarction in dorsolateral to the fourth
ventricle or nodulus
Solitary plaque involving the brachium
conjunctivum