Supine roll test (Pagnini-McClure)
Diagnostic test for lateral / horizontal canal BPPV. Distinguishes geotropic from apogeotropic variants by the direction of provoked nystagmus.
Indication
Performed when the Dix-Hallpike is negative or atypical but positional vertigo persists, or when posterior canal repositioning has produced a 'canal conversion' to horizontal canal nystagmus.
Procedure
Step 1 of 4Patient supine, head flexed 30°
Patient lies flat on the couch with the head supported in 30° of flexion (a pillow under the upper back works well). This brings the lateral semicircular canal into the vertical plane.
Expected finding
Geotropic horizontal nystagmus (beating toward the earth on both sides, more intense when the affected ear is down) indicates canalithiasis of the lateral canal — affected ear is the side with the more intense response. Apogeotropic nystagmus (beating toward the ceiling on both sides) suggests cupulolithiasis or a variant — affected ear is the side with the LESS intense response.
Cautions
- Same as Dix-Hallpike — cervical instability, severe cervical disease, or carotid pathology.
References
- Bhattacharyya N, Gubbels SP, Schwartz SR, Edlow JA, El-Kashlan H, Fife T, et al. (2017). Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngology — Head and Neck Surgery, 156(3 Suppl):S1–S47. link