Dix-Hallpike Maneuver in Posterior BPPV with Reversal of Nystagmus on Sitting Up

𝗢𝗿𝗶𝗴𝗶𝗻𝗮𝗹 𝗗𝗲𝘀𝗰𝗿𝗶𝗽𝘁𝗶𝗼𝗻: This is a patient with typical posterior canal (PC) benign paroxysmal positional vertigo (BPPV), which is provoked by the Dix-Hallpike maneuver. When the patient is moved into the right Dix-Hallpike maneuver, after a brief latency, upbeat-torsional (towards the lowermost or affected [right] ear) nystagmus is seen. There is a crescendo-decrescendo pattern and nystagmus and vertigo resolve. With the right Dix-Hallpike maneuver, the right PC is stimulated by movement of the otoconial particles and an excitatory pattern of nystagmus results. In this case, the right superior oblique and left inferior rectus muscles are stimulated which initiates the downward and torsional (towards left ear) slow phase. An upbeat-torsional (towards right ear) fast phase is then generated until the otoconia fall to the most dependent portion of the PC and there is no longer flow of endolymph or deflection of the cupula. However, when the patient is brought from right Dix-Hallpike back to a seated position, the otoconia move in the opposite (inhibitory) direction, and a downbeat-torsional nystagmus is then seen. [[Number of Videos and legend for each: A patient with posterior canal BPPV and reversal of nystagmus when going from Dix-Hallpike to seated positions. ]] 𝗡𝗲𝘂𝗿𝗼-𝗼𝗽𝗵𝘁𝗵𝗮𝗹𝗺𝗼𝗹𝗼𝗴𝘆 𝗮𝗻𝗱 𝗡𝗲𝘂𝗿𝗼-𝗼𝘁𝗼𝗹𝗼𝗴𝘆 𝗧𝗲𝘅𝘁𝗯𝗼𝗼𝗸 𝗟𝗲𝗴𝗲𝗻𝗱: This is a patient with typical posterior canal (PC) benign paroxysmal positional vertigo (BPPV), which was provoked by the Dix-Hallpike maneuver. When the patient is moved into the right Dix-Hallpike maneuver, after a brief latency, upbeat-torsional (toward the lowermost or affected [right] ear) nystagmus is seen. There is a crescendo-decrescendo pattern and nystagmus and vertigo resolve. With the right Dix-Hallpike maneuver, the right PC is stimulated by movement of the otoconial particles and an excitatory pattern of nystagmus results. In this case, the right superior oblique and left inferior rectus muscles are stimulated which initiates the downward and torsional (toward left ear) slow phase. An upbeat-torsional (toward right ear) fast phase is then generated until the otoconia fall to the most dependent portion of the PC and there is no longer flow of endolymph or deflection of the cupula. However, when the patient is brought from right Dix-Hallpike back to a seated position, the otoconia move in the opposite (inhibitory) direction, and a downbeat-torsional nystagmus is then seen https://collections.lib.utah.edu/details?id=1281864. (Video courtesy of Dr. Marco Mandala)