Dix-Hallpike & Epley Maneuver Test

by Carlo Raj, MD

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    00:01 Here, we have vestibular neuronitis.

    00:04 An acute unilateral peripheral vestibulopathy.

    00:08 No evidence of inflammation.

    00:09 Sudden or spontaneous vertigo associated with nausea and vomiting.

    00:13 Symptoms will peak within 24 hours.

    00:16 Resolves over days or weeks.

    00:18 And unilateral nystagmus may be seen.

    00:20 It can be suppressed by visual fixation.

    00:24 That’s the clinical pearl here.

    00:26 It can be suppressed by actual visual fixation.

    00:29 This is known as your vestibular neuronitis.

    00:33 What is labyrinthine concussion? It’s a head injury in which maybe perhaps there was or wasn’t a skull fracture.

    00:42 Maybe associated with hearing loss and tinnitus.

    00:45 Infarction: If there’s a problem with the vertebrobasilar system including your posterior inferior cerebellar artery, anterior inferior cerebellar artery, or maybe perhaps even your spinal cerebral artery.

    00:59 Associated with brainstem signs including cranial nerve, and we have weakness, ataxia.

    01:05 The central-type nystagmus: Pure vertical or pure horizontal, may be bilateral.

    01:12 Are not suppressed by visual fixation.

    01:14 That’s important for you to pay attention to here once again.

    01:17 Not suppressed by visual fixation.

    01:20 This is the central type of nystagmus.

    01:23 What is Ménière's disease? Episodic vertigo with nausea and vomiting.

    01:28 Fluctuating, but progressive hearing loss.

    01:33 Tinnitus and sensation of fullness in the ear, your clinical pearl here is fullness in the ear and caused by increased endolymphatic volume or perhaps pressure.

    01:44 Ménière's disease.

    01:48 Perilymphatic fistula: As the name implies, a fistula.

    01:52 Where? Abrupt onset of vertigo which then persists episodically.

    01:59 Often precedes by hearing a pop in the affected ear with sneezing, coughing, or blowing or straining.

    02:07 A fistula, a perilymphatic, can be treated with rest or a fat patch if refractory.

    02:14 Pop, perilymphatic, if that helps you.

    02:20 BPPV, benign positional paroxysmal vertigo.

    02:24 This is episodic vertigo, however, triggered by head movement.

    02:28 Episodes are brief, but severe.

    02:30 Associated with latency, finite duration and fatigue.

    02:36 Often associated with severe nausea and vomiting caused by floating calcium carbonate crystals in the endolymph.

    02:43 Pathology here, calcium carbonate actually floating in your endolymph.

    02:49 Characteristic downbeating torsional nystagmus on Dix-Hallpike testing.

    02:56 Downbeating torsional nystagmus.

    03:01 It can be rapidly treated with what’s known as your Epley repositioning maneuver.

    03:07 Here, what we have known as benign positional paroxysmal vertigo.

    03:13 So what is the Dix-Hallpike or Epley maneuver? Well, what you’re looking at here is a patient that was sitting up.

    03:21 And then you’re going to have them lay down in supine position.

    03:25 I’m having you move from left to right.

    03:29 And as you do so, you’ll notice here the degree of changes that are taking place with each position.

    03:37 The first picture on your left, the patient is sitting straight up, the patient next is then moving back to a 45-degree angle.

    03:45 The patient after that is moved down to a 90-degree angle.

    03:49 The patient now has then turned over to the side, maintaining that 90-degree angle and the patient is able to get back up or sit back up.

    04:02 All this is referred to as being your Dix-Hallpike or Epley maneuver.

    04:08 And this is in reference to a diagnosis that we just discussed known as your benign positional paroxysmal vertigo, BPPV.

    04:22 What are pearls for vertigo? Tinnitus and hearing loss accompanied peripheral vertigo.

    04:28 Diplopia, dysarthria, and other brainstem signs point to a central cause.

    04:35 Isolated vertigo is almost never caused by brainstem ischemia.

    04:41 And BPPV, your benign positional paroxysmal vertigo, is the most common cause of new onset vertigo.

    04:51 And I just walked you through the Epley maneuver.

    About the Lecture

    The lecture Dix-Hallpike & Epley Maneuver Test by Carlo Raj, MD is from the course Vertigo and Dizziness. It contains the following chapters:

    • Vertigo
    • Dix-Hallpike/Epley Maneuver & Vertigo Pearls

    Included Quiz Questions

    1. Calcium carbonate crystals in the endolymph.
    2. Oxalate crystals in the endolymph.
    3. Calcium carbonate crystals in the external ear.
    4. Calcium crystals on the tympanic membrane.
    5. Calcium carbonate crystals in the perilymph.
    1. Increased endolymphatic volume.
    2. Decreased endolymphatic volume.
    3. Decreased perilymphatic volume.
    4. Increased perilymphatic volume.
    5. Fracture of stapes.
    1. It can be suppressed by visual fixation
    2. Tinnitus
    3. Caused by inflammation
    4. Bilateral nystagmus
    5. Resolves within minutes
    1. Benign paroxysmal positional vertigo
    2. Ménière's disease
    3. Vestibular neuronitis
    4. Perilymphatic fistula
    5. Labyrinthine concussion

    Author of lecture Dix-Hallpike & Epley Maneuver Test

     Carlo Raj, MD

    Carlo Raj, MD

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