Tool
Test Explorer
18 bedside tests, each mapped to what it interrogates, the positive response, the localising value, and the conditions it characteristically picks up. Filter by tier or by urgency, or search for a feature.
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Showing 18 of 18 bedside tests
Dix-Hallpike manoeuvre
localisingPosterior-canal BPPV.
- Procedure
- Seated, head turned 45° to the tested side; lay supine quickly with head extended 20° below horizontal; observe the eyes.
- Positive sign
- Torsional-upbeat nystagmus toward the dependent (affected) ear with short latency (5–15 s), crescendo–decrescendo, lasting <60 s, fatiguing on repeat.
- Localises
- Posterior semicircular canal of the dependent ear.
- Bedside value
- Gold standard for PC-BPPV; sensitivity 79–88%, specificity 75–100%. Confirms the diagnosis and identifies the canal to repose with the Epley.
Supine roll (Pagnini–McClure)
localisingLateral-canal (horizontal) BPPV.
- Procedure
- Supine with head flexed 30°; rotate the head 90° to each side in turn and hold for ~60 s; observe horizontal nystagmus.
- Positive sign
- Geotropic horizontal nystagmus (beating to the ground, stronger side affected) = canalithiasis. Apogeotropic (beating away, weaker side affected) = cupulolithiasis.
- Localises
- Horizontal semicircular canal.
- Bedside value
- First-line test for suspected HC-BPPV; the geotropic-vs-apogeotropic pattern dictates the repositioning manoeuvre (Lempert barbecue or Gufoni).
Straight Head Hanging Test
localisingAnterior-canal BPPV (rare).
- Procedure
- Supine; head extended 30–45° below horizontal in the midline; observe.
- Positive sign
- Pure or mainly downbeating vertical nystagmus with short latency and fatigue.
- Localises
- Anterior canal (rare). Persistent, non-fatiguing downbeat instead suggests a craniocervical-junction or cerebellar lesion.
- Bedside value
- Most sensitive positional test for AC-BPPV. Sustained downbeat without fatigue must prompt imaging.
Head Impulse Test
localisingImage nowHorizontal vestibulo-ocular reflex.
- Procedure
- Patient fixates the examiner's nose; deliver a small, unpredictable, fast head turn (10–20°) to each side.
- Positive sign
- Overt corrective catch-up saccade after the head stops — the eye briefly travels with the head and snaps back to target.
- Localises
- Peripheral vestibular afferent on the tested side (canal or vestibular nerve).
- Bedside value
- Lateralises peripheral hypofunction. A NORMAL HIT in active acute vertigo paradoxically points to a central lesion — the heart of HINTS.
Spontaneous & gaze-evoked nystagmus
localisingImage nowDirection, plane, and modulation of nystagmus at the bedside.
- Procedure
- Observe in primary gaze and on lateral/up/down eccentric gaze; remove fixation with Frenzel goggles or ophthalmoscope.
- Positive sign
- Unidirectional, horizontal-torsional, fixation-suppressed, Alexander's-law-obeying = peripheral. Vertical, purely torsional, direction-changing, or fixation-resistant = central.
- Localises
- Peripheral labyrinth/nerve vs central (brainstem or cerebellum), depending on the pattern.
- Bedside value
- The single most informative bedside observation. Drives the differential before any manoeuvre.
Test of Skew
localisingImage nowVertical ocular misalignment from otolith-ocular pathway imbalance.
- Procedure
- Patient fixates distance; cover one eye then the other while watching the uncovered eye for a vertical refixation movement.
- Positive sign
- Vertical corrective movement on uncovering — skew present.
- Localises
- Central — brainstem (vestibular nuclei), cerebellum, or thalamus.
- Bedside value
- The 'S' of HINTS. Present in central but rare in isolated peripheral lesions.
HINTS battery
localisingImage nowDifferentiate central from peripheral acute vestibular syndrome.
- Procedure
- Combine the head impulse test, nystagmus observation, and test of skew on a patient with active AVS.
- Positive sign
- ANY one of: normal HIT, direction-changing nystagmus, or skew present → central pattern (INFARCT).
- Localises
- Posterior-circulation stroke until proven otherwise when the pattern is central.
- Bedside value
- More sensitive than early DWI-MRI (<48 h) for posterior-fossa infarction in expert hands. HINTS-plus adds bedside hearing screen.
Romberg test
screeningProprioceptive and vestibular contributions to postural balance.
- Procedure
- Feet together, arms by sides; stand 30 s with eyes open then with eyes closed.
- Positive sign
- Stable with eyes open but unsteady or falls with eyes closed.
- Localises
- Sensory ataxia — vestibular hypofunction or dorsal-column (proprioceptive) loss. Unsteady with eyes open suggests cerebellar disease instead.
- Bedside value
- Screens for sensory-versus-cerebellar contributions. Non-lateralising; a positive test does not localise to one labyrinth.
Sharpened (tandem) Romberg
screeningSubtle balance deficit unmasked by a narrower base of support.
- Procedure
- Tandem stance (heel-to-toe), eyes closed; hold 30 s.
- Positive sign
- Stepping out, falls, or excessive sway — more sensitive than standard Romberg.
- Localises
- Same as Romberg but uncovers compensated unilateral vestibular loss.
- Bedside value
- Recommended in chronic dizziness and post-rehab follow-up when standard Romberg is negative.
Fukuda stepping test
lateralisingVestibulospinal tone asymmetry.
- Procedure
- March in place 50–100 steps with arms outstretched, eyes closed, in a quiet room.
- Positive sign
- Rotational drift > 30° from the start position.
- Localises
- Rotates toward the side of vestibular hypofunction (lateralising). Cerebellar lesions produce irregular drift.
- Bedside value
- Adjunctive — modest sensitivity and specificity. Useful alongside HIT and nystagmus pattern.
Unterberger stepping test
lateralisingVestibulospinal tone asymmetry (a Fukuda variant).
- Procedure
- Identical to Fukuda; some examiners emphasise lateral displacement as well as rotation.
- Positive sign
- Rotation > 30° toward the hypofunctioning ear.
- Localises
- Same as Fukuda. Limited specificity in isolation.
- Bedside value
- Confirmatory only — interpret with HIT, nystagmus, and history.
Past pointing
lateralisingTonic vestibulospinal drift in the upper limb.
- Procedure
- Patient raises an arm overhead and lowers it to touch the examiner's outstretched finger, eyes closed; repeat several times.
- Positive sign
- Reproducible deviation toward one side.
- Localises
- Drift toward the side of peripheral vestibular hypofunction. Asymmetric overshoot/dysmetria suggests cerebellar disease instead.
- Bedside value
- Lateralising adjunct in a wider bedside battery.
Tandem gait
screeningCerebellar and vestibular contributions to walking.
- Procedure
- Walk heel-to-toe along a straight line for 10 steps.
- Positive sign
- Steps off the line, wide base, or inability to perform.
- Localises
- Cerebellar (broad-based, irregular), vestibular (lateralised veering), or functional (cautious freezing).
- Bedside value
- Sensitive, non-specific — pair with HIT, HINTS, and Romberg.
CTSIB (foam Romberg)
screeningSensory integration — vestibular contribution unmasked.
- Procedure
- Romberg variant on a compliant foam pad with feet together; eyes open then closed.
- Positive sign
- Marked sway or step-out / fall in the eyes-closed-on-foam condition.
- Localises
- Vestibular dominance: when proprioception is degraded by the foam and vision is removed, the patient must rely on vestibular input — bilateral or severe unilateral loss fails dramatically.
- Bedside value
- The most informative bedside posture test for vestibular contribution; quantifiable extension of the standard Romberg.
Hennebert sign
localisingPressure-induced eye / head movements — third-window detection.
- Procedure
- Apply positive then negative pressure via a pneumatic otoscope (or tragal compression) to the external auditory canal.
- Positive sign
- Vertigo, nystagmus or head deviation provoked by pressure change. Movement plane reflects the affected canal.
- Localises
- Superior canal dehiscence, perilymph fistula, large vestibular aqueduct — any third window into the membranous labyrinth.
- Bedside value
- Quick bedside screen for third-window pathology; should be paired with the Tullio test and a CT temporal bone if positive.
Tullio phenomenon
localisingSound-induced vestibular response — third-window detection.
- Procedure
- Present a loud tone (typically 100–110 dB SPL) to the affected ear via headphones or free-field speaker.
- Positive sign
- Vertical-torsional eye movement (SSCD) or horizontal nystagmus (perilymph fistula) appearing in time with the stimulus.
- Localises
- Third-window pathology — SSCD characteristically gives an eye movement aligned with the dehiscent superior canal.
- Bedside value
- Pathognomonic when classical — strong indication for high-resolution temporal-bone CT and VEMP threshold testing.
Vertebral artery compression test
lateralisingImage nowPosition-related vertebrobasilar insufficiency — Bow Hunter's screen.
- Procedure
- Patient seated; passively rotate and extend the head to each side and hold for 30–45 s while observing for symptoms or nystagmus.
- Positive sign
- Reproducible vertigo, nystagmus, diplopia, dysarthria, or drop attack induced by head rotation.
- Localises
- Mechanical compression of one vertebral artery, typically at the C1–C2 articulation, in a setting of cervical spondylosis or contralateral VA hypoplasia.
- Bedside value
- Provocative test with real clinical risk — perform with caution, support ready, and stop at the first symptom. Confirm with dynamic vertebral-artery imaging.
Mini-Cog (3-word recall + clock draw)
screeningBedside cognitive screen — uncover occult cognitive impairment in dizzy elderly.
- Procedure
- Register 3 words; clock-drawing distractor task; recall the 3 words.
- Positive sign
- Total ≤ 2 of 5 (1 point per recalled word, 2 for a correctly drawn clock) flags possible cognitive impairment.
- Localises
- Cortical / global cognitive function. A positive screen reframes the work-up around geriatric assessment and falls, not the vestibular battery.
- Bedside value
- A 3-minute screen with high yield in elderly dizziness; changes downstream investigations and referrals.