Impact of head orientation and head movement in traditional manual diagnostics of benign paroxysmal positional vertigo: a randomized controlled crossover study

Malene Hentze^1,2*Dan Dupont Hougaard^1,2Herman Kingma^1,2

• ¹Balance and Dizziness Center, Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Aalborg University Hospital,, Aalborg, Denmark
• ²Department of Clinical Medicine, Aalborg University, Aalborg, Denmark

Background: Tradititional manual diagnostics of Benign Paroxysmal Positional Vertigo (BPPV) include Supine Roll test (SRT) and Dix-Hallpike test (DHT). However, the influence of head orientation and -movement on the diagnostic performance remains unclear. Objective: To assess how head orientation and -movement affect the diagnostic performance of the manual SRT and DHT. Method: This prospective, randomized, crossover study was conducted at a tertiary university hospital outpatient clinic. Participants with suspected BPPV (n=198) underwent (in random order) both manual and mechanical rotation chair (MRC)-based (gold standard) SRT and DHT. BPPV diagnosis required characteristic positional nystagmus. Participants were grouped as: 1) true positives (manual and MRC diagnostics detection the same BPPV nystagmus) and 2) false negatives (manual: negative, MRC: positive). Primary outcome was difference in head orientation and -movement between groups. Secondary outcome was minimal head orientation required for BPPV nystagmus detection in the manual tests.Results: With manual SRT, yaw head angles were substantially below the 90° target (right: 70.3° (95% CI: 68.7, 71.9); left: -66.2° (95% CI: -67.7, -64.6)). Manual SRT missed a large proportion of BPPV (right: 63.3%; left: 62.5%). A minimum yaw angle of approximately ±55° appeared necessary for BPPV nystagmus detection. For the pitch angle, overshooting the -60° target (to -75°) seemed more effective than undershooting. For manual DHT, yaw angles were closer to target ±45°, though left DHT was less accurate (right: 47.4° (95% CI: 46.2, 48.7); left: -33.3° (95% CI: -34.6, -31,9)). BPPV detection rates were higher (right: 73.2%; left: 65.9%), with a tendency toward better outcome when yaw head angle was overshot, and pitch angle ranged from -100° to -120°. Head movements varied narrowly, making it challenging to determine minimal values. No differences in head movements were found between true positive and false negative groups. Conclusion: Manual DHT effectively detected posterior BPPV. In contrast, manual SRT (without truncal rotation), lacking sufficient yaw rotation, missed most lateral BPPV. Therefore, we recommend performing manual SRT with full-body rotation or upper trunk rotation. Future research is encouraged to define optimal head orientation and -movement in BPPV diagnostics. The level of evidence: IV Trial registration: ClinicalTrials.gov identifier: NCT05846711