Administration

Abnormal result

Normal result

Dix-Hallpike test for posterior BPPV

While the patient’s head is oriented 45 degrees to the tested ear, lie them down quickly from a seated position to supine, with head extending ~30 degrees below horizontal

Nystagmus (vertical upbeating and torsional beating toward downward eye) after seconds, lasting <1 min, with associated vertiginous symptoms that are fatigable

No nystagmus or vertiginous symptoms

Head impulse test for peripheral versus central vertigo

While the patient is instructed to stare at the examiner’s nose, apply brief, high-acceleration, horizontal head impulses in the excitatory direction of each canal, >15 degrees in each direction

After a head impulse towards a lesioned/hypoactive labyrinth, the vestibulo-ocular reflex will show decreased gain, moving the eye insufficiently to compensate for head motion, leading to a rapid saccade to bring the eyes back to the intended point of fixation

Patient’s eyes remain stable on the examiner (in the setting of vertigo it indicates peripheral vertigo)

Hennebert sign for third window disease/fistula

Vertigo/nystagmus evoked by changes in pressure in the inner ear (to increase intracranial pressure: Valsalva maneuver with a closed glottis; to increase middle ear pressure: Valsalva maneuver with an open glottis and nose pinch)

Tullio phenomenon for third window disease/fistula

Vertigo/nystagmus during exposure to loud sounds