Exploring the Role of the Head Rotation Sit-Up Test in Identifying Epley-Responsive, Non-Classical Presentations of BPPV

<i>Background and Objectives</i>: The Dix-Hallpike test (DHT) is the standard diagnostic maneuver for posterior semicircular canal benign paroxysmal positional vertigo (BPPV). However, some patients present with positional symptoms compatible with BPPV yet show no observable nystagmus on the DHT. We introduced the Head Rotation Sit-up Test (HRST) as a symptom-based maneuver and hypothesized that it would identify DHT-negative patients who nonetheless benefit from canalith repositioning. This study aimed to explore the potential role of the HRST. It was introduced as a complementary, symptom-based maneuver for evaluating non-classical vertigo presentations. <i>Materials and Methods</i>: We retrospectively reviewed patients clinically suspected of having BPPV by the attending physicians at Nara Medical University Hospital (August 2018-July 2022). All underwent both the DHT and HRST; those positive on either test received the Epley maneuver and were included. Patients were categorized as Group 1: DHT(-)/HRST(+), and Group 2: DHT(+), irrespective of the HRST, for the purpose of comparing patients who were positive on the HRST with those positive on the DHT. Post-treatment symptom severity was assessed on a 0-10 scale, with the patient's most severe pre-treatment symptom defined as 10, and responder rates (post-Epley score < 5) were compared. <i>Results</i>: Among 179 patients with suspected BPPV, 80 were test-positive and were treated with the Epley maneuver. Group 1 comprised 31 patients, who more commonly reported non-rotational symptoms such as floating or unsteadiness, whereas rotational vertigo predominated in Group 2 (<i>n</i> = 49). Median post-Epley scores were significantly lower after treatment in both groups (Group 1: 2 [IQR 0-3]; Group 2: 3 [IQR 0-5]). Group 1 demonstrated a higher responder rate than Group 2 (90.3% vs. 65.3%, <i>p</i> = 0.016). Within Group 2, outcomes did not differ significantly between DHT(+)/HRST(+) and DHT(+)/HRST(-) subgroups. <i>Conclusions</i>: The HRST identified a clinically relevant subgroup of DHT-negative patients who nevertheless responded favorably to the Epley maneuver. Incorporating the HRST alongside the DHT may expand the diagnostic reach for BPPV, particularly among patients with non-classical symptoms or without observable nystagmus. These findings support the HRST as a useful complementary maneuver for detecting Epley responsive, symptom based positional vertigo.