Epley Maneuver

Anatomy and Physiology

BPPV is among the most common inner ear disorders that cause dizziness or vertigo.[4] The disease process appears to be caused by otoliths that become displaced in the semicircular canal.[5] The majority of these otoliths can be found in the posterior semicircular canal, followed by horizontal (lateral).[5] These otoliths move due to gravity as the head is turning and cause inappropriate signaling that the head is moving when, in reality, it is not. When the vestibular apparatus, semicircular canals, and visual system are disequilibrium, it elicits the sensation of dizziness. The classic symptoms of BPPV often involve brief episodes of rotational vertigo that are reproducible.[6] The most common cause of BPPV is primary or "idiopathic,” as BPPV itself is often found in isolation. However, other inner ear pathologies such as Meniere disease and even migraines have links to BPPV.[7][8] Other common causes include head trauma and inner ear surgeries, which can often dislodge otoliths into the semicircular canals.

Indications

History and physical exams are pertinent in diagnosing BPPV correctly. The classic symptoms of BPPV often include sudden onset vertigo, worsened by head movements. These attacks can last for under one minute. However, patients have described them as lasting much longer due to associated nausea and disequilibrium. When the clinician has diagnosed BPPV, the clinician has likely ruled out more dangerous etiologies of dizziness; it is crucial to communicate with the patient to assuage their fears because many patients present concerned about the more dire causes of dizziness, such as an intracranial mass or a stroke. Following a thorough history and physical exam, and the dizziness determined to be secondary to a peripheral cause, the Dix-Hallpike maneuver can be an option. If the etiology of the dizziness is unknown or if a central lesion is a consideration, other physical exam maneuvers, such as the HiNTS exam, should be employed to further aid in narrowing the differential diagnosis.

Contraindications

There are few contraindications to the Dix-Hallpike maneuver; however, providers need to consider the patient’s physical anatomy and neck mobility concerning their ability to tolerate the quick actions and movements required to perform the maneuver. Patients with cervical spinal stenosis or limited cervical mobility may not tolerate the procedure well due to the quick cervical spine rotation and hyperextension needed for success.[9] In a small study of 50 emergency physicians, barriers that contributed to decreased use of either the Dix-Hallpike maneuver or Epley maneuver included negative experiences associated with performing it, forgetting how to perform the maneuver, or relying on a history of present illness to diagnose BPPV. Overall, these physicians still had positive experiences utilizing the Dix-Hallpike or Epley maneuvers.[10]

Equipment

The absolute equipment required includes:

• Examination table

Optional equipment and materials include:

• Intravenous access equipment
• Premedication with antiemetics such as ondansetron, promethazine, or meclizine
• Emesis bag
• Pillow positioned under the shoulders for hyperextension of the neck

Using antiemetics before the Epley maneuver can provide comfort and temporary relief of nausea and emesis associated with the maneuver.

Personnel

The Epley Maneuver is performable with one operator. Nursing staff can also be available at the bedside should the operator need assistance with moving the patient.

Preparation

Utilize the Dix-Hallpike maneuver prior to performing the Epley Maneuver, as it will allow for localization of the canalith. The following scenario will assume otolith localization to the right inner ear; simply reverse the directions if the otolith is on the contralateral side. A pillow may be placed on the bed and used to allow for the extension of the head past the horizontal.

Positioning: The patient is seated on the exam table, upright. The operator is standing behind the patient, near the head of the bed.

Technique or Treatment

The examiner rotates the patient’s head 45 degrees to the right and quickly lays the head back over the end table. The patient’s eyes should exhibit torsional nystagmus. Each position should be held for at least 30 seconds. As the nystagmus improves, the otolith descends and is in an optimal position for the next step. Rotate the patient’s head 90 degrees to the left, again holding for at least 30 seconds. Instruct the patient to turn their entire head and body in the left lateral position, with the head facing 135 degrees from supine or 225 degrees from the starting position (looking at the floor). Assist the patient in returning back to the sitting supine position while holding their head in place. The head position should be maintained as they are assisted in the sitting position, and repeat if necessary.

Complications

Some complications of using the technique include the inability to tolerate the quick movements needed to perform the maneuver successfully. Neck mobility requires an assessment before the maneuver. The operator should anticipate nausea and emesis; thus, premedication with an antiemetic such as ondansetron or promethazine is optional. In a Cochrane review, nausea was the most commonly cited symptom, which may cause intolerance to the procedure.[11]

Clinical Significance

The Epley maneuver is a low-cost, safe, and relatively benign treatment option for benign paroxysmal positional vertigo. It requires few resources and is a simple bedside solution to BPPV, whether in the clinic or emergency department. In a Cochrane review that compared the Epley maneuver to a control or sham maneuver, the Epley had a significant likelihood of symptom resolution (OR, 4.4%; NNT, 3).[11]

Enhancing Healthcare Team Outcomes

The interprofessional team is vital to the treatment of BPPV while using the Epley maneuver. Though the procedure only requires one operator, the situation may require anticipation of adverse side effects to produce satisfactory care. The physician, physician assistant, or nurse practitioner performing the procedure should anticipate nausea and vomiting; thus, communication with the nursing staff is vital to ensure the patient is either premedicated with an antiemetic or has these medications readily drawn in the event the patient requires it.

Nursing, Allied Health, and Interprofessional Team Monitoring

The nursing team should continue to monitor for nausea and vomiting during and after the procedure.