Supine Roll Test (Pagnini-McClure Maneuver)

This video illustrates bedside technique for the supine roll test (also known as the Pagnini-McClure maneuver) for horizontal canal benign paroxysmal positional vertigo (BPPV).This maneuver is specific for horizontal canal BPPV in the same way that the Dix-Hallpike maneuver is specific for posterior canal BPPV. The goal of the test is to provoke symptoms and nystagmus that will allow accurate diagnosis. In the video, the test is illustrated in a normal subject, so nystagmus is absent. The ideal head position is with the horizontal semicircular canals in a plane perpendicular to the floor (parallel to gravity). This can be accomplished by tucking the chin 30 degrees forward (either by elevating the back of the head manually, as shown, or by placing a supporting pillow under the head) or by inclining the examining table 30 degrees (reverse Trendelenburg position, i.e., with head above feet). In patients with horizontal canal BPPV, a brisk horizontal nystagmus will develop within a few seconds after turning the head to one or both sides. If the positioning is correct and the BPPV is restricted to the horizontal canal, the nystagmus vector should be purely horizontal. The direction of the nystagmus will differ depending on the location of the pathological otoliths in the horizontal canal (long arm vs. short arm) and the side being tested. Note that the nystagmus may occur while testing one or both sides, even if the disease is unilateral. In general, when testing the side that is most symptomatic (i.e., with the most intense vertigo and nystagmus) the nystagmus will initially beat towards the affected ear, whether that nystagmus is beating towards the floor (geotropic) or the ceiling (apogeotropic). The majority of patients will have bilateral geotropic nystagmus (i.e., beating rightward when the right ear faces the floor and leftward when the left ear faces the floor). The affected side can usually be determined by nystagmus intensity (with geotropic nystagmus, the stronger nystagmus intensity occurs with affected side's ear facing the floor). If the intensity is similar to either side, any initial nystagmus on reclining into the neutral supine position (i.e., with the patient viewing the ceiling) will usually beat away from the affected side (i.e., left-beating when the right horizontal canal is involved). Note that, after an initial burst of beating towards the floor, the geotropic nystagmus may damp and reverse direction spontaneously (i.e., to apogeotropic) even with the head held in a stable position. This sort of reversal is generally only seen with the geotropic variant. Some patients will have bilateral apogeotropic nystagmus (i.e., beating leftward when the right ear faces the floor and rightward when the left ear faces the floor). The affected side can usually be determined by nystagmus intensity (with apogeotropic nystagmus, the stronger nystagmus intensity occurs with affected side's ear facing the ceiling). If the intensity is similar to either side, any initial nystagmus on reclining into the neutral supine position (i.e., with the patient viewing the ceiling) will usually beat towards the affected side (i.e., right-beating when the right horizontal canal is involved). In addition, any nystagmus following head shaking while seated upright will usually beat away from the affected side (i.e., left-beating when the right horizontal canal is involved). This sort of head shaking nystagmus is generally only seen with the apogeotropic variant.