Contraindications to the Dix-Hallpike manoeuvre: A multidisciplinary review: Contraindicaciones de la maniobra de Dix-Hallpike: Una revisión. Here, we present an abbreviated variation of the Dix–Hallpike .. Riveros H, Anabalon J, Correa C. Resultados de la nueva maniobra de. Evaluar la efectividad de la maniobra de Epley para el VPPB del canal posterior. Conversión del resultado de la prueba posicional de Dix‐Hallpike de.
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Benign paroxysmal mainobra vertigo BPPV secondary to canalolithiasis of the posterior semicircular canal is perhaps the most frequent cause of vertigo and dizziness. One of its properties is a high response rate to canalith repositioning maneuvers. However, delays in the diagnosis and treatment of this entity can range from days to years, depending on the setting.
Here, we present an abbreviated variation of the Dix—Hallpike maneuver, which can be used to diagnose this disease. A diagnostic assessment study was conducted in patients who presented with vertigo or dizziness. This new diagnostic maneuver may serve as a screening procedure for quickly identifying this pathology. This will allow patients to be more directly treated, without requiring unnecessary referrals or full vestibular testing, and will be especially useful in primary care settings or heavily overloaded otolaryngology or neurology departments.
This version is useful for diagnosing the posterior canalolithiasis variant of benign paroxysmal positional vertigo BPPV. We propose that this diagnostic tool has practical value, particularly for physicians who are not specialized in vestibular disorders because it will help them to easily identify a large majority of simple BPPV cases, thus allowing instant treatment for these patients and avoiding unnecessary referrals.
This reliable and easy-to-perform diagnostic maneuver does not require an examination bed or table. Benign paroxysmal positional vertigo is the most frequent cause of vertigo, with a lifetime prevalence of 2. The prevalence of BPPV increases with age and is associated with an increased risk of falling, which is a major health issue in the elderly 45. Originally described by Robert Barany in 6 and properly defined by Margaret Dix and Charles Hallpike in 7BPPV is clinically characterized by brief spells of positional vertigo or dizziness these symptoms are triggered by a change in the position of the head in space relative to gravity that can last from a few seconds to a few minutes 89.
Benign paroxysmal positional vertigo represents a common clinical entity that is encountered not only by specialists in neuro-otology and balance disorders but also by non-specialized otolaryngologists, neurologists, or geriatricians and general practitioners in primary care or emergency departments, among many other settings, in routine clinical practice 10 — It is widely accepted that BPPV is caused by the dislodgement of otoconia from the otolith macula 8 These particles then float until they become trapped within a semicircular canal canalolithiasis or attached to its cupula cupulolithiasis.
Then, after a change in head position in the plane of the affected canal, gravity induces the trapped otoconia to move, resulting in abnormal endolymph flow and the subsequent deflection of the cupula in cases of canalolithiasis or direct cupular deflection in cases of cupulolithiasis. The computation of this asymmetry at the vestibular nuclei triggers not only vertigo or dizziness but also a specific type of nystagmus that depends on the canal that is affected by the disease.
Test de Dix-Hallpike
All three semicircular canals can be afflicted by this condition 11 — It is therefore the single most common specific cause of vertigo 12 — The posterior canals share their plane of rotation with the anterior canal of the contralateral ear. The disposition of semicircular canals. A Head in a neutral position. A With the head in an upright position, a dislodged otoconia is shown in a pc-BPPV patient to be resting within the posterior canal near the cupula region.
This generates ampullofugal endolymph flow, which deflects the cupula away from the vestibule. Nystagmus characteristic of pc-BPPV. A A right pc-BPPV will present, after a Dix—Hallpike maneuver, with nystagmus accompanied by a quick phase that beats upward and rotates toward the affected ear e.
Dix–Hallpike test – Wikipedia
The eye rotates three-dimensionally in the Manikbra plane. From a frontal perspective, this is perceived mahiobra a mixed vertical and torsional manoobra. B If the patient is asked to look to the left, thus aligning his gaze with the LARP plane, the pupil will beat upward in this plane, isolating the vertical component. In this position, the pupil is near the axis of rotation, therefore isolating the torsional component.
These eye movements can be better evaluated by shifting the mmaniobra sideways. In this setting, only the vertical nystagmus component will be visualized as a slow phase pulling the eyes downward in this diagonal hallpime and a visible quick phase directing them upward. Usually, patients are examined while their gaze is neutral and forward. Another key feature of pc-BPPV is its excellent response to treatment 1418in that the immediate disappearance of the positional nystagmus and other symptoms after performing canalith repositioning procedures CRPs is viewed as strongly supporting the diagnosis 8.
Both the Semont and, in particular, the Epley CRPs have been shown to reliably resolve most pc-BPPV cases, even when applied maniobrw a single procedure that was only a few minutes in duration 1419 — It has been proposed that in these cases, the amount of loose otoconia is sufficient to produce symptoms but is insufficient to trigger abnormal eye movement responses 823hlalpike In these cases, improvement in symptomatology after CRPs supports both the idea that subjective pc-BPPV is a valid entity and the manioba of diagnosis on a patient to patient basis Haplpike, many patients with this condition wait several months or even years to have it properly diagnosed and treated 25 The delay in diagnosis and treatment of BPPV has been attributed to many different causes.
There is a tendency in some settings to refer all cases of vertigo to otolaryngology, neurology, or vertigo-specialized units, which overload these specialties 126 Manlobra, even in simple and uncomplicated BPPV cases, unnecessary imaging and vestibular tests are frequently ordered However, for non-specialized neurologists, otolaryngologists, or general practitioners, performing a simple sDH may be a greater challenge than referring the patient for full vestibular testing.
In many settings, particularly in overloaded mahiobra care facilities and even many otolaryngology practices, the underlying reason for this behavior is that the practitioner does not have easy access to an examination table or bed to perform testing.
Given the above information, we believe that developing an abbreviated and easy-to-teach diagnostic maneuver that requires minimal infrastructure to be performed and that focuses solely on pc-BPPV as the single most common cause of vertigo may lead to a screening-like procedure for this entity, and this may lead to an instant diagnosis—treatment algorithm that will ideally decrease unnecessary referrals and patient care delays.
We then conducted a diagnostic test to evaluate the effectiveness of this new maneuver in which we used the sDH as the gold standard. We intentionally describe the test as being performed without Frenzel glasses or a video-oculography device. These devices are of extraordinary value when assessing pathological eye movements and vestibular disorders, but we intended to the APCCAM to require a minimum of material aids to support its widespread, non-specialized use.
This step is critical for securing a wider range of neck movement. Performing the mini Dix—Hallpike maneuver. A First, the patient is asked to sit on the halllpike edge of a backed chair. C The patient is pulled backward into a resting position against the back of the chair.
As previously explained, this is key to assessing the posterior canal of the right ear. As in step 1, this allows a wider range of neck movement. This resembles the main action performed in the sDH and is responsible for the diix rotation and translation of the posterior canal relative to gravity. Steps 3 and 4 should be carried out as seamlessly and as quickly as possible. Steps 2—4 should be repeated to assess the posterior canal of the contralateral ear.
We decided to evaluate two independent positive results as potential diagnostic criteria supporting pc-BPPV:.
We acknowledge the possibility of bilateral pc-BPPV. This may prove to be a limitation of this tool over time, but at this stage, we feel confident in making unilaterality a criterion for a positive diagnosis.
A diagnostic test study was conducted. From January to Februarypatients presenting with vertigo or dizziness to one of these five physicians at the Otolaryngology Department of the Hospital San Juan de Dios in Santiago de Chile were invited to participate.
The exclusion criteria included severe neck, ophthalmological, or neurological pathology, previously known vestibular disorders, or the presence of spontaneous nystagmus.
An appointment for vestibular testing including complete positional testing was then scheduled. As a result of scheduling overloads in our department, this appointment did not occur on the same day as the initial medical assessment. We note this to acknowledge that the known elements of BPPV fatigability with positional testing were ruled out.
The sDH jallpike performed at this second stage with the support of video-oculography. For the purposes of this study, only the triggering of nystagmus was considered to be a positive abnormal sDH result.
If abnormal findings other than those associated haallpike BPPV were found, the patient was scheduled for medical reassessment. If pc-BPPV was detected at this stage, the Epley CRP was immediately performed, and the patient was scheduled for weekly follow-ups until the positional vertigo and nystagmus disappeared. A total of patients participated in the study.
They had an average age of In terms of gender, patients The average delay between symptom onset and assessment was Furthermore, 31 patients Overall, 76 patients No patients presented with nystagmus or phenomena, suggesting central positional nystagmus. The sequence of positions, translations, and rotations that are performed to move the head in space relative manipbra gravity follow the same principles as the sDH. This compromises the range, speed, and fluidness of the traditional maneuver.
Moreover, and further diminishing the theoretical reliability of this canalolithiasis diagnostic maneuver, we tested the APCCAM without using Frenzel glasses or video-oculography.
However, considering triggered symptomatology alone to be sufficient for establishing a diagnosis may appear to be a leap of faith in the context of subjective BPPV, an entity that is still debated by clinicians 23 The patient reported no further vertigo spells at home during follow-up, and the disease was considered resolved.
Whether the absence of nystagmus on the APCCAM in the symptom-only patients was caused by the lower range of head movements that were associated with the maneuver or by the absence of video-oculography during the eye movement assessment is a question that we did not address in this study. This will therefore be the focus of future research. Many nallpike practicing in primary care or emergency departments, in addition to many otolaryngologists and neurologists, are not properly specialized in vestibular disorders and may find treating patients with vertigo or dizziness to be challenging.
The tendency to refer patients and to order routine imaging or vestibular tests varies across different settings. However, as described above, these can be very frequent, which can lead to delays in the diagnosis and treatment of simple cases of BPPV.
Even if we ignored the full range of vestibular disorders, it can take years to acquire the skills and knowledge necessary to manage BPPV and all of its variants. Hence, even experts find some cases to be extremely challenging. However, the maneuver proposed in this study is intended for diagnosing only one variant, and in this context, we believe it will be easy to teach.
In support of its use, we have chosen to provide a detailed explanation of the mechanisms and principles that are involved in canal alignment, which underlies the effects of the APCCAM that are described in the introductory segment of this article. This could lead directly to CRP. The actual impact of this diagnostic maneuver on hallpkie referral rates, the numbers of tests ordered, and the daily activities of medical centers that treat patients with vertigo, including primary care centers, emergency departments, and vestibular-specialized units, remains to be seen.
However, at least in this initial study, the APCCAM appears to be a sensitive and specific tool that can identify the leading and most easily solvable cause of vertigo, BPPV, using a maneuver that can be easily taught and that requires only a backed chair.
All authors contributed to patient assessment and data retrieval. PM and CO had a key role in the general coordination of the whole project and in statistical analysis particularly CO.
PM and HB were officially responsible for the project. HB and Halppike wrote the manuscript. All authors participated actively in the corrections and further development of the manuscript.