Epley Maneuver

Epley Maneuver for posterior canal BPPV

Begin with the patient’s head turned 45 degrees toward the affected side.	Bring to a supine position with the head turned toward the affected side and hanging 20°.

Rotate the patient’s head 90 degrees toward the unaffected side.	Guide the patient to the side lying position with their nose pointing to the ground.	While keeping the head in 45º, tucked position, return the patient to a seated position.

Helpful hints

1. Consider using VNG

It is most helpful to utilize Frenzel lenses or VNG while performing CRP. This reduces the ability of the patient to fixate during the procedure in an attempt to reduce the nystagmus response. This will also allow the examiner to see even very slight torsional nystagmus.

2. Past injuries

Before performing any positioning maneuver, it is important to ascertain whether the patient has current or past injuries of the neck or spine.

3. Neurological symptoms

If neurological symptoms occur during the execution of positioning maneuvers, discontinue the procedure immediately and refer for a neurological evaluation. These symptoms might include, blurred vision, numbness, weakness of the arms or legs or confusion.

4. Efficacy

Efficacy of the procedure is increased to more than 90% if CRP is performed twice in rapid succession.

5. Postural support

It is not unusual for the patient to lose postural control at the completion of the procedure due to the otoconia briskly falling within the cupula. It is vital that the examiner is in a stance that will provide postural support to the patient.

6. Watch for changes in nystagmus

It is important to watch for changes in the nystagmus upon completion of the procedure: a reversal of nystagmus indicates that the otoconia fell back into the canal; an upbeat nystagmus indicates that the otoconia fell back into the cupula.

Epley maneuver procedure

1. Begin with the patient sitting length-wise on the examination table.
2. Place the Frenzel/VNG goggles on the patient.
3. Have the patient turn his head to a 45º angle toward the side that you are going to treat (the affected side).
4. While maintaining the 45º head position, guide the patient in a continuous motion from sitting to lying with the head hanging off the table at approximately 20º. It is imperative to provide cervical support during this portion of the procedure.
5. Hold this position for 30-60 seconds.
6. Maintain the 20º head extension and rotate the patient’s head 90º toward the unaffected side so that the patient’s head is approximately 45º toward the unaffected side.
7. Hold this position for 30-60 seconds.
8. While still maintaining the 45º head position, guide the patient into a side-lying position on the shoulder of the unaffected side. The patient’s nose should be pointed toward the floor.
9. Hold this position for 30-60 seconds.
10. Instruct the patient to tuck his chin and maintain the 45º head position.
11. Guide the patient back into a sitting position while ensuring that the patient’s head remains at the 45º angle and the chin remains tucked.

References

• Epley J. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 1992;107:399-404
• Honrubia V, Baloh RW, Harris MR, et al. Paroxysmal positional vertigo syndrome. Am J Otol. 1999;20:465-470
• Sherman D, Massoud EA. Treatment outcomes of benign paroxysmal positional vertigo. J Otolaryngol 2001;30:295-299.