What is the test for vertigo called?

Benign Paroxysmal Positional Vertigo

Benign paroxysmal positional vertigo (BPPV) is a disease of the vestibular system of your inner ear. When you change your head position, it causes vertigo. Vertigo is a feeling that the room is spinning around you.

Your vestibular system helps sense motion and changes in space. It adds to your sense of balance. The vestibular organs are inside the innermost part of your ear. They include the utricle, saccule, and 3 semicircular canals. When your head moves, these small organs send this information to the brain.

The utricle contains small calcium crystals. These help you to sense motion. Sometimes these crystals detach from the utricle and land in one of the semicircular canals. Then the canals may send the wrong signals to the brain, especially when the crystals move. This confuses the brain and leads to BPPV symptoms.

The condition is called benign because it is not life-threatening. It does not get worse with time. Paroxysmal means that the vertigo comes and goes. Positional just means that symptoms come from a change in head position.

BPPV is fairly common, especially in women. Older adults have it more often. But people of any age can get it. It is one of the most common vestibular disorders.

What causes benign paroxysmal positional vertigo?

Anything that dislodges the crystals from the utricle can cause BPPV. Having a past head injury is a major cause. Other times, BPPV may result from other problems with the vestibular system. These can include Ménière disease or vestibular neuritis. Ear surgery is a less common cause. In most cases, no one knows exactly what causes BPPV.

Who is at risk for benign paroxysmal positional vertigo?

People with certain health conditions may have a higher risk for BPPV. But many times the cause is not known. You may have a higher risk of developing BPPV if you have any of these:

Migraine
Giant cell arteritis
High blood pressure
High cholesterol or other blood lipids
History of stroke
Head injury

It’s not clear if treating these conditions might reduce your risk for BPPV.

What are the symptoms of benign paroxysmal positional vertigo?

The most common BPPV symptoms include:

A feeling of spinning (vertigo)
Lightheadedness
Trouble with balance
Nausea and vomiting

Certain types of movement can bring on symptoms. Symptoms then often last a minute or less. Common triggers are rolling over in bed or looking up while standing. These symptoms can vary in how often they happen and how severe they are. In some people, these symptoms are so severe that they disrupt personal and work life.

Very often, the symptoms go away and then come back weeks or months later. Without treatment, symptoms might continue for a few weeks before going away. In a small number of people, the symptoms never come back after the first time.

Unlike some other causes of vertigo, BPPV doesn’t cause nervous system symptoms such as severe headache, speech problems, or loss of limb movement. It also doesn’t cause hearing problems.

The symptoms of BPPV may seem like those of other health conditions. Always see your healthcare provider for a diagnosis.

How is benign paroxysmal positional vertigo diagnosed?

BPPV may be diagnosed and treated by your primary healthcare provider. Or by an ear, nose, and throat doctor (otolaryngologist). Or it may be diagnosed and treated by a neurologist. The provider will ask about your health history. You may also have a physical exam. This may include hearing and balance tests. It will also include an exam of the nervous and cardiovascular systems. Problems with these systems can also cause vertigo.

As part of the exam, your healthcare provider may have you do certain movements. These will include moving your head and body in certain ways. If you have BPPV, this test can bring on vertigo. It can also bring on quick, involuntary eye movements (nystagmus). Your provider can also use this test to find which semicircular canal is most likely affected.

If your healthcare provider is still not sure about the diagnosis, you may need other tests such as:

ENG (electronystagmography). This test uses electrodes to test your eye movements in response to stimuli that may cause your vertigo.
VNG (videonystagmography). This test is similar to an ENG but it uses cameras instead. Your eyes are a part of your sense of balance. So ENG and VNG tests may help find the cause of your vertigo.
Imaging tests. Tests such as an MRI can help rule out nervous system problems as a cause.

How is benign paroxysmal positional vertigo treated?

Treatment will depend on your symptoms, age, and general health. It will also depend on how severe the condition is.

First your healthcare provider may try to move the calcium crystals out of your semicircular canals. This may be done with a series of certain head and neck movements. This often takes about 15 minutes. Your provider may tell you to do certain movements at home. This treatment often works. Some people may still have vertigo with head movement for a few weeks.

Special physical therapy may also be part of your treatment.

Medicines are not often given for BPPV. This is because most of them don’t help. In some cases, short-term use of motion sickness medicines may help to ease nausea.

If these other treatments fail, in rare cases your healthcare provider may advise surgery. One option is called posterior canal plugging. It blocks the movement of calcium crystals in the posterior semicircular canal. The surgery can work well. But in rare cases, it can cause some hearing loss.

Your healthcare provider may also advise a watch-and-wait approach to your BPPV before trying surgery. BPPV does often go away on its own over time. But in many cases it does come back. If you are still having symptoms from BPPV, your healthcare provider may tell you how to prevent symptoms. For example:

Using 2 pillows in bed to raise your head
Not sleeping on your affected side
Rising slowly out of bed
Not looking up
Not bending over to pick things up
Not doing exercises that use head rotation, such as swimming laps

Even if you stop having symptoms, your healthcare provider may suggest that you follow similar instructions, at least for a few weeks. This may help prevent your symptoms from coming back.

Key points about benign paroxysmal positional vertigo

BPPV is a disease that affects the vestibular system of the inner ear. With changes of head position, it causes sudden vertigo and related symptoms.
Head injury and past vestibular disorders can cause BPPV. But many times the cause is not known.
Symptoms typically happen with head movement. The vertigo lasts only a short while, but it may come back many times.
BPPV often responds to treatment with physical movements. But in rare cases some people with severe BPPV may need surgery.
As you are recovering from BPPV, you may need to not make certain head movements to help prevent your symptoms from coming back.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

Know the reason for your visit and what you want to happen.
Before your visit, write down questions you want answered.
Bring someone with you to help you ask questions and remember what your provider tells you.
At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.
Know why a new medicine or treatment is prescribed, and how it will help you. Also know what the side effects are.
Ask if your condition can be treated in other ways.
Know why a test or procedure is recommended and what the results could mean.
Know what to expect if you do not take the medicine or have the test or procedure.
If you have a follow-up appointment, write down the date, time, and purpose for that visit.
Know how you can contact your provider if you have questions.

Medical Reviewer: Ashutosh Kacker MD
Medical Reviewer: Ronald Karlin MD
Medical Reviewer: Daphne Pierce-Smith RN MSN CCRC

Videonystagmography

A videonystagmography (VNG) test uses a special set of goggles with a camera to record your eye movements. It looks for a specific type of eye movement called nystagmus. Your healthcare provider may order this test if you have symptoms of an inner ear disorder.

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Overview

What is a videonystagmography?

A videonystagmography (VNG) is a test that evaluates your eye movements. It looks for a specific type of eye movement called nystagmus. Nystagmus happens when your eyes move uncontrollably up and down or side to side. These movements may be rapid or slow.

You may get nystagmus briefly when you move your head in certain directions. But if you get nystagmus when you’re sitting still or for long periods, it could point to an inner ear (vestibular) disorder.

When is a VNG needed?

You may need a VNG test if you have symptoms that could point to an inner ear disorder, such as:

Balance problems.
Dizziness.
Feelings of pressure or fullness in your ears.
Lightheadedness.
Tinnitus (ringing in your ears).
Vertigo.

What does a VNG test diagnose?

Healthcare providers use VNG tests to diagnose vestibular disorders, including:

Acoustic neuroma.
Benign paroxysmal positional vertigo (BPPV).
Labyrinthitis.
Ménière’s disease.
Vestibular neuritis.

What is the difference between a VNG and an ENG test?

A VNG test uses special goggles and infrared cameras. An electronystagmography (ENG) uses small electrodes placed around your eyes.

Both VNGs and ENGs give your healthcare provider similar information about your vestibular nerve and inner ear function.

Who performs a VNG?

Several specialists may perform a VNG test, including:

Audiologists, physicians specializing in hearing and balance disorders.
Otolaryngologists, physicians specializing in conditions that affect the ear, nose and throat.
Neurologists, physicians specializing in the brain and nervous system.

Test Details

How does a VNG test work?

In a VNG test, you sit in a dark exam room wearing a special set of goggles. The goggles have a camera in them that records your eye movements.

Your healthcare provider asks you to watch lights moving on a TV screen or move your head and body in certain positions. Your healthcare provider may also send small bursts of warm or cold water or air into your ears. The goggles record how your eyes move in response to these different actions.

How do I prepare for a VNG test?

Your healthcare provider will give you specific instructions to prepare for a VNG test. Most people don’t need to do anything special.

Tell your healthcare provider about all medications and supplements you take. You may have to stop taking certain medicines for a brief period before the test.

What should I expect during a VNG test?

On the day of the test, you sit in the exam room and put on the goggles. Then, your healthcare provider guides you through the three parts of the test:

Ocular testing: You watch different dots or flashes of light while keeping your head still.
Positional testing: Your healthcare provider instructs you to move your head or body to different positions.
Caloric testing: Your healthcare provider sends small bursts of warm or cool air or water into each ear. These bursts of air or water should cause nystagmus.

A VNG test usually lasts around 60 minutes.

What should I expect after a VNG test?

You may feel slightly dizzy during and immediately after the test. Usually, dizziness goes away quickly. If it lingers, you’ll need someone to drive you home.

Results and Follow-Up

What do the results of a VNG test mean?

You may have an inner ear or balance disorder if your eyes don’t move as expected during the VNG test. Your healthcare provider may order more follow-up tests or offer treatment options depending on your results.

Additional Details

Is a VNG test uncomfortable?

You may feel some discomfort during a VNG test, but it’s usually minimal. You may feel slightly dizzy after the test, too. You may also have some discomfort from wearing the goggles for an extended period. These symptoms usually go away quickly.

A note from Cleveland Clinic

A videonystagmography (VNG) is a test to evaluate your eye movements that relate to your vestibular (inner ear balance system). Your healthcare provider may recommend a VNG if they suspect you have an inner ear disorder. You may have an inner ear or balance disorder if your eyes don’t move as expected during the VNG test.

Dix–Hallpike test

The Dix–Hallpike [1] or Nylén–Bárány [2] test is a diagnostic maneuver from the group of rotation tests used to identify benign paroxysmal positional vertigo (BPPV).

Dix–Hallpike test
ICD-9-CM	95.45

1 Procedure
2 Interpretation
- 2.1 Positive test result
- 2.2 Negative test
Procedure Edit
When performing the Dix–Hallpike test, patients are lowered quickly to a supine position (lying horizontally with the face and torso facing up) with the neck extended 30 degrees below horizontal by the clinician performing the maneuver. [3]
The Dix–Hallpike and the side-lying testing position have yielded similar results. As such, the side-lying position can be used if the Dix–Hallpike cannot be performed easily. [4]
1. perform first with the right ear down
2. perform next with the left ear down
The examiner looks for nystagmus (usually accompanied by vertigo). In BPPV, the nystagmus typically occurs in A or B only, and is torsional—the fast phase beating toward the lower ear. Its onset is usually delayed a few seconds, and it lasts 10–20 seconds. As the patient is returned to the upright position, transient nystagmus may occur in the opposite direction. Both nystagmus and vertigo typically decrease on repeat testing.
Interpretation Edit
Positive test result Edit
A positive test is indicated by patient report of a reproduction of vertigo and clinician observation of nystagmus (involuntary eye movement).
For some patients, this maneuver may be contraindicated, and a modification may be needed that also targets the posterior semicircular canal. Such patients include those who are too anxious about eliciting the uncomfortable symptoms of vertigo, and those who may not have the range of motion necessary to comfortably be in a supine position. The modification involves the patient moving from a seated position to side-lying without their head extending off the examination table, such as with Dix–Hallpike. The head is rotated 45 degrees away from the side being tested, and the eyes are examined for nystagmus.
Negative test Edit
If the test is negative, it makes benign positional vertigo a less likely diagnosis and central nervous system involvement should be considered.
Advantages Edit
Although there are alternative methods to administering the test, Cohen proposes advantages to the classic maneuver. The test can be easily administered by a single examiner, which prevents the need for external aid. Due to the position of the subject and the examiner, nystagmus, if present, can be observed directly by the examiner. [4]
Limitations Edit
The negative predictive value of this test is not 100%. Some patients with a history of BPPV will not have a positive test result. The estimated sensitivity is 79%, along with an estimated specificity of 75%.
The test may need to be performed more than once, as it is not always easy to demonstrate observable nystagmus that is typical of BPPV. Also, the test results can be affected by the speed with which the maneuver is conducted and the plane of the occiput. [5]
There are several disadvantages proposed by Cohen for the classic maneuver. Patients may be too tense, for fear of producing vertigo symptoms, which can prevent the necessary brisk passive movements for the test. A subject must have adequate cervical spine range of motion to allow neck extension, as well as trunk and hip range of motion to lie supine. From the previous point, the use of this maneuver can be limited by musculoskeletal and obesity issues in a subject. [4]
Precautions and contraindications Edit
In rare cases a patient may be unable or unwilling to participate in the Dix–Hallpike test due to physical limitations. In these circumstances the side-lying test or other alternative tests may be used. [6]
Precautions
- The Dix–Hallpike maneuver places a degree of stress on the patient’s lower back; therefore, a cautious approach must be taken with patients who are suffering from back pain. [7]
- Severe respiratory or cardiac problems may not allow a patient to tolerate the maneuver. For example a patient with orthopnoea may not be able to participate in the procedure, as the patient may have troubling breathing when lying down. [7]
1. Neck surgery [7]
2. Severe rheumatoid arthritis[7]
3. Atlantoaxial and occipitoatlantal instability [7]
4. Aplasia of odontoid process[7]
5. Cervical myelopathy[7]
6. Cervical radiculopathy[7]
7. Carotid sinus syncope[7]
8. Vascular dissection syndromes [7]
See also Edit
- Tilt table test
- Epley maneuver – used to treat BPPV
Footnotes Edit
1. ^ Dix MR, Hallpike CS (1952). «The pathology symptomatology and diagnosis of certain common disorders of the vestibular system» (Scanned & PDF) . Proc. R. Soc. Med. 45 (6): 341–54. PMC1987487 . PMID14941845.
2. ^
3. Lanska, DJ; Remler, B (May 1997). «Benign paroxysmal positioning vertigo: classic descriptions, origins of the provocative positioning technique, and conceptual developments». Neurology. 48 (5): 1167–77. doi:10.1212/wnl.48.5.1167. PMID9153438. S2CID41403974.
4. ^
5. Sumner, Amanda (2012). «The Dix-Hallpike Test» (PDF) . Journal of Physiotherapy. 58 (2): 131. doi: 10.1016/S1836-9553(12)70097-8 . PMID22613247.
6. ^ abc
7. Cohen, H.S. (2004). «Side-Lying as an Alternative to the Dix-Hallpike Test of the Posterior Canal». Otology & Neurotology. 25 (2): 130–134. doi:10.1097/00129492-200403000-00008. PMID15021771. S2CID12649245.
8. ^
9. Bhattari H (2010). «Benign Paroxysmal Positional Vertigo: Present Perspective». Nepalese Journal of ENT Head and Neck Surgery. 1 (2): 28–32. doi: 10.3126/njenthns.v1i2.4764 .
10. ^
11. Halker B, Barrs D, Wellik K, Wingerchuk D, Demaerschalk B (2008). «Establishing a Diagnosis of Benign Paroxysmal Positional Vertigo Through the Dix-Hallpike and Side-Lying Maneuvers: A Critically Appraised Topic». The Neurologist. 14 (3): 201–204. doi:10.1097/NRL.0b013e31816f2820. PMID18469678. S2CID24468873.
12. ^ abcdefghij
13. Humphriss, Rachel; Baguley D; Sparks V; Peerman S; Mofat D (2003). «Contraindications to the Dix–Hallpike manoeuvre: a multidisciplinary review». International Journal of Audiology. 42 (3): 166–173. doi:10.3109/14992020309090426. PMID12705782. S2CID13536408.
External links Edit
- Overview and diagrams at dizziness-and-balance.com
- video of Dix–Hallpike test