Dix Hallpike Maneuver: Evaluation of Balance Stones (Ear Rocks / Small Crystals / Otoconia)) in Inner Ear

Gold Standard Test For Diagnosis of Posterior Canal Benign Paroxysmal Positional Vertigo (BPPV)

Dizziness - assessing the causes of vertigo and making the diagnosis is not always easy. "Dix Hallpike Maneuver" can, when used appropriately, identify a common cause of benign vertigo (BPPV) that can be treated with treatment maneuvers that provide immediate relief to patients.

Posterior canal benign paroxysmal positional vertigo

Guidelines on BPPV from AAO-HNS (American Academy of Otorhinolaryngology and Head and Neck Surgery) state that posterior canal BPPV diagnosis was made with a history of episodic positional vertigo and a characteristic nystagmus finding revealed by Dix-Hallpike test. The use of the Dix-Hallpike test as a diagnostic maneuver for posterior canal BPPV was described in 1952.38 The patient was moved to a supine position with the head tilted 45 degrees and the neck extended with the tested ear extended down. . It should be done on both sides, especially if the first test is negative.

Dix Hallpike Maneuver (or Dix Hallpike Test) aims to define benign paroxysmal positional vertigo (BPPV). This disease process is thought to result from free-floating stones (often called calcium carbonate stones, otoliths) in the semicircular canals of the inner ear. This system forms three channels each forming a ring filled with endolymph and covered with hair cells. During the normal rotational movement of the head, the liquid endolymph remains relatively inactive as the channels and hair cells move. The hair cells are mechanically pushed by the resistance of the endolymph and the mechanically gated ion channels are opened, triggering an action potential that demonstrates rotational movement. Each of the three channels, with the front and rear channels in the vertical plane adjusted to detect movement in the sagittal and coronal planes, and the lateral channel 30 degrees from the horizontal channel, left or right in the horizontal plane.

BPPV typically dislocates a piece of calcium carbonate from the autoconical membrane in one of the channels, physically dislocates the moving hair cells, and creates permanent action potentials until the reaction is exhausted, typically between 30 and 60 seconds. This results in vertigo movement and nystagmus characteristics in short paroxysms with changes in head position. The posterior canal is the affected canal in 90% of benign positional paroxysmal vertigo, and lateral canal pathology causes about 8% of cases. Dix-Hallpike maneuver is the gold standard for the diagnosis of benign positional paroxysmal vertigo caused by posterior canal otolith. The patient head is positioned backward and leaning against the affected ear, causing the otolith to advance along the natural course of the canal. Typically, after a delay of five to 20 seconds, this causes vertigo to be resolved within 60 seconds and a rotating or upward nystagmus.

Dix Hallpike Maneuver Indications

Dix-Hallpike maneuver is indicated for patients with paroxysmal vertigo who are considered to have benign positional paroxysmal vertigo. These patients experience vertigo in short episodes lasting less than one minute with changes in head position and return to total normality between attacks. Mild dizziness or nausea may take longer than one minute, but if the sensation of movement persists for more than one minute, alternative diagnoses should be considered. Dizziness is a common complaint and serious causes should be considered and excluded first. Non-paroxysmal vertigo is caused by central etiology such as vestibular syndrome or brainstem stroke. Distinguishing these causes requires extensive neurological examination (possibly including HINTS examination), a detailed history, and possibly computerized tomography screening and MRI imaging as indicated. Any neurological deficiency, especially truncal ataxia, should raise concern for a central cause and trigger further studies. Dix-Hallpike maneuver is the preferred test for diagnosis in posterior akanal benign positional paroxysmal vertigo.

Contraindications For Dix Hallpike Maneuver

In a patient with neck pathology, Dix-Hallpike maneuver should be avoided where the movements may be dangerous for the patient. Cervical instability, vertebrobasilar insufficiency and vascular problems such as carotid sinus syncope, acute neck trauma and cervical disc prolapse are absolute contraindications. In patients without absolute contraindications, it may be appropriate to briefly evaluate neck rotation and extension before attempting maneuver to see if these positions can be maintained comfortably for thirty seconds.

Why is Dix Hallpike Maneuver Necessary?

A bed or stretcher is required in which the patient can hang his head backwards; But some equipment can help if you have. Frenzel goggles can be useful for magnifying the movements of the eyes. A mat table can be useful to lift shoulders and keep the patient close to the ground and thus safer. Video ENG devices can be used by advanced practitioners to better monitor eye movements during this maneuver.

Dix Hallpike Maneuver Technique

Dix Hallpike Maneuver

The patient begins to sit and their heads are directed 45 degrees to the ear to be tested. The clinician then extend to engage the head end of the bed of the patient quickly, or head and neck while preserving the first rotation of 20 degrees below horizontal. The clinician then monitors the patient's eyes for torsion and ascending nystagmus, which should begin after a short delay and not last longer than one minute. This indicates a positive test. If the test is negative but the clinical suspicion is high, the patient should be given a chance to recover for at least one minute and then the other ear can be tested. Lateral canal pathology may not be detected by this method, and if this is suspected, a supine rolling test may be performed.

Tips on The Dix-Hallpike Maneuver and The Epley Maneuver

During the test, the head should be turned 45 degrees, if the head is turned 90 degrees, dizziness and nystagmus may occur on both sides and may mislead the physician.

۞ For test positivity, nystagmus in the eyes is necessary, not the dizziness expressed by the patient.

If nystagmus, which has typical features on the side where the head is tilted, is observed in the Dix Hallpike test, the maneuver can be turned to the Epley Maneuver (the maneuver to seat the crystals) by turning the head to the opposite side without sitting the patient.

Geotropic rotatory nystagmus is observed in classical posterior canal BPPV. The upper pole of the eyes turns towards the affected ear.

۞ Completely horizontal nystagmus shows horizontal canal involvement.

۞ Persistent (not tiring) nystagmus may indicate cananalolitiasis rather than cupulolitiasis.

۞ The nystagmus in the eyes should be e

Dix Hallpike Maneuver Complications

Nausea and vomiting are common during this maneuver; this can potentially be avoided by giving an antiemetic before testing.

Clinical Importance of Dix Hallpike Maneuver

Dix-Hallpike maneuver is the gold standard for the diagnosis of benign paroxysmal positional vertigo, so it is difficult to assess the sensitivity and specificity as acute. Exclusion of Hazardous etiology of vertigo, the clinician requires excellent history and physical examination skills should be the primary concern. After this etiology rejected, while the differential benign paroxysmal positioning vertigo Dix-Hallpike maneuver can diagnose the problem. This is the position of the otolith continues to be manipulated until the rear channels, which ended with vertigo sensation changes and improves the position of the Epley maneuver easily passed the disease process. Although a high relapse rate and this not always effective, it is highly desirable to alleviate the symptoms of our patients in this way and that patients are given instructions on how to do it at home for relapse.

Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon - ENT Doctor in Istanbul

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