• See Also
  1. HiNTs Exam (Three-Step Bedside Oculomotor Examination)
  2. Horizontal Head Impulse Test (Head Thrust Test, h-HIT)
  3. Nystagmus
  4. Skew Deviation (Vertical Ocular Misalignment, Vertical Heterotropia, Vertical Strabismus)
  5. Vertigo
  6. Vertigo Causes
  7. Peripheral Causes of Vertigo
  8. Central Causes of Vertigo
  9. Vertigo Management
  10. Meniere's Disease
  11. Motion Sickness
  12. Vestibular Neuronitis
  13. Benign Paroxysmal Positional Vertigo
  14. Perilymphatic Fistula (Hennebert's Sign)
  15. Acute Labyrinthitis
  16. Bacterial Labyrinthitis (Acute Suppurative Labyrinthitis)
  17. Dizziness
  18. Dysequilibrium
  19. Syncope
  20. Light Headedness
  • Indication
  1. Vestibular Testing for Benign Paroxysmal Positional Vertigo
    1. Vertigo evoked by position change (triggered Vertigo)
    2. No symptoms at rest
  • Contraindications
  1. Elderly with significant carotid vascular disease
  2. Unstable spinal disorder
  3. Acute vesitibular syndrome (non-triggered Vertigo)
  • Procedure
  1. Patient starts in sitting position on exam table
    1. Facing forward with eyes open
  2. Rapidly lie patient backward (patient keeps eyes open and focused)
    1. Head turned 45 degrees to RIGHT
    2. Neck extended 20 degrees hanging over end of table
    3. Patient remains in this position for 30 seconds
    4. Vertigo or Nystagmus suggests right ear vestibular canal involvement
  3. Sit patient up
  4. Rapidly lie patient backward (patient keeps eyes open and focused)
    1. Head turned 45 degrees to LEFT
    2. Neck extended 20 degrees hanging over end of table
    3. Patient remains in this position for 30 seconds
    4. Vertigo or Nystagmus suggests left ear vestibular canal involvement
  5. Observe for symptoms triggered by Vertigo (lasting a minute or less)
    1. Vertiginous symptoms
    2. Nystagmus
      1. Upbeat or torsional Nystagmus (posterior canal)
      2. Downbeat Nystagmus (anterior canal)
  • Interpretation
  1. Tests only anterior and posterior canal
    1. Horizontal canal is NOT tested (but could be tested with a supine roll test)
  2. Positive signs suggestive of Benign Paroxysmal Positional Vertigo
    1. Vertigo
    2. Nystagmus
      1. Downbeat Nystagmus (anterior canal)
      2. Upbeat Nystagmus (posterior canal)
      3. Rotary or torsional Nystagmus (posterior canal)
        1. Globe torques around central axis
        2. Counterclockwise or clockwise
    3. Latent period (1 to 10 seconds) follows procedure before Nystagmus, Vertigo
    4. Response Fatigues or habituates on repetition
  • Efficacy
  1. See HiNTs Exam (Three-Step Bedside Oculomotor Examination) as a better alternative for the acute Vertigo evaluation
  2. Identifies the affected ear in BPPV
  3. Unreliable in distinguishing peripheral Vertigo from central Vertigo (Cerebrovascular Accident)
    1. Kerber (2009) Emerg Med Clin North Am 27(1): 39-50 [PubMed]
  • References
  1. Warrington (2022) Crit Dec Emerg Med 36(12): 16-7