T. D. Fife, MD,
D. J. Iverson, MD,
T. Lempert, MD,
J. M. Furman, MD, PhD,
R. W. Baloh, MD,
R. J. Tusa, MD, PhD,
T. C. Hain, MD,
S. Herdman, PT, PhD, FAPTA,
M. J. Morrow, MD and
G. S. Gronseth, MD
From the Barrow Neurological Institute and University of Arizona College of Medicine (T.D.F.), Phoenix, AZ; Humboldt Neurological Medical Group, Inc. (D.J.I.), Eureka, CA; Department of Neurology (T.L.), Schlosspark-Klinik, Berlin, Germany; Department of Otolaryngology (J.M.F.), University of Pittsburgh, PA; Department of Neurology (R.W.B.), Reed Neurological Research Center, University of California, Los Angeles, CA; Departments of Neurology (R.J.T.) and Rehabilitation Medicine (S.H.), Emory University; Atlanta, GA; Northwestern University (T.C.H.), Chicago, IL; Providence Multiple Sclerosis Center (M.J.M.), Portland, OR; and University of Kansas (G.S.G.), Kansas City, KS.
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Figure 1 Dix–Hallpike maneuver for diagnosis of right posterior canal benign paroxysmal positional vertigo (BPPV)
The patient’s head is turned 45 degrees toward the side to be tested and then laid back quickly. If BPPV is present, nystagmus ensues usually within seconds.
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Figure 2 Canalith repositioning procedure for right-sided benign paroxysmal positional vertigo
Steps 1 and 2 are identical to the Dix–Hallpike maneuver. The patient is held in the right head hanging position (Step 2) for 20 to 30 seconds, and then in Step 3 the head is turned 90 degrees toward the unaffected side. Step 3 is held for 20 to 30 seconds before turning the head another 90 degrees (Step 4) so the head is nearly in the face-down position. Step 4 is held for 20 to 30 seconds, and then the patient is brought to the sitting up position. The movement of the otolith material within the labyrinth is depicted with each step, showing how otoliths are moved from the semicircular canal to the vestibule. Although it is advisable for the examiner to guide the patient through these steps, it is the patient’s head position that is the key to a successful treatment.
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Figure 3 Semont maneuver for right-sided benign paroxysmal positional vertigo
While sitting up in Step 1, the patient’s head is turned 45 degrees toward the left side, and then the patient is rapidly moved to the side-lying position as depicted in Step 2. This position is held for 30 seconds or so, and then the patient is rapidly taken to the opposite side-lying position without pausing in the sitting position or changing the head position relative to the shoulder. This is in contrast to the Brandt–Daroff exercises that entail pausing in the sitting position and turning the head with body position changes.
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Figure 4 Supine roll test (Pagnini–McClure maneuver) to detect horizontal canal benign paroxysmal positional vertigo (BPPV)
The patient may be taken from sitting to straight supine position (1). The head is turned to the right side (2) with observation of nystagmus and then turned back to face up (1). Then the head is turned to the left side (3). The side with the most prominent nystagmus is taken to be the affected horizontal semicircular canal. The direction of nystagmus in each position determines whether the horizontal canal BPPV is of the geotropic or apogeotropic type.
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Figure 5 Lempert roll maneuver for right-sided horizontal canal benign paroxysmal positional vertigo (BPPV)
When it is determined to be horizontal canal BPPV affecting the right side, the patient is taken through a series of step-wise 90-degree turns away from the affected side in Steps 1 through 5, holding each position for 10 to 30 seconds. From Step 5, the patient positions his or her body to the back (6) in preparation for the rapid and simultaneous movement from the supine face up to the sitting position (7).
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