Benign Positional Vertigo in Emergency Medicine Treatment & Management

If the history and physical examination are typical, no further evaluation is necessary, and the emergency physician may proceed with the modified Epley maneuver described below (see the video below).

If the history and physical examination findings are atypical, consider other causes of positional vertigo, which may occur with tumor or infarcts in the posterior fossa.

Contraindications to performing the Epley maneuver include ongoing CNS disease (ie, stroke or transient ischemic attack [TIA]), unstable heart disease, severe neck disease (eg, rheumatoid arthritis) or history of cervical spine fracture or surgery, carotid bruit on examination indicating carotid stenosis, or body habitus preventing performance of the maneuver.

Further information on diagnosis and treatment guidelines and recommendations are available from the American Academy of Neurology and the American Academy of Otolaryngology-Head and Neck Surgery Foundation.^{[2, 4]}

The goal of the Epley maneuver is to move the otoliths out of the posterior semicircular canal and back into the utricle where they belong.

The success rate of the Epley maneuver is very high (approximately 85-90%). When it fails, it is the author's experience that it is being incorrectly applied to patients with vestibular neuritis or labyrinthitis.

Epley maneuver, general guidelines

The head must be in the dependent (head-hanging) position for this maneuver to work. If the patient does not tolerate this position, put the gurney in the Trendelenburg position to simulate this head-hanging position.^[5]

Maintain each position until the symptoms and nystagmus have disappeared or for at least 30 seconds.

If the patient cannot tolerate the maneuver because of vomiting or severity of the vertigo, premedicate with a vestibular sedative, such as 25 mg IV promethazine (Phenergan).

Epley maneuver steps

Have the patient sit upright on the gurney with the head turned 45° to the affected side (this was predetermined by using the Hallpike test). Make sure the patient is sitting far enough back in the gurney so that the head will hang over the edge of the gurney when the patient is laid back. Make sure the guardrail on the opposite side has been lowered (the patient will eventually sit up so his or her legs overhang the edge of the gurney). See the image below.

Place your hands on either side of the patient's head and guide the patient down with the head dependent (as in the Hallpike test). See the image below.

Rotate the head 90° to the opposite side with the patient's face upward and be sure to maintain the head-dependent position (head is hanging over the edge of the gurney).

Ask the patient to roll onto his or her side while holding the head in this position and then rotate the head so that it is facing downward (tell the patient to look to the ground). See the images below.

Raise the patient to a sitting position while maintaining head rotation (This author finds that sitting the patient up so that he or she is sitting with his or her legs hanging over the edge of the gurney is easier. This is why the side guardrails need to be lowered before the procedure is started). See the images below.

Simultaneously rotate the head to a central position and move it 45° forward.

The Semont maneuver (liberatory maneuver)

This maneuver is primarily used in Europe. Although it can be used to treat classic posterior canal BPV, in the United States, it is usually reserved to treat the cupulolithiasis form of BPV (where the otoliths are not free-floating but instead are attached to the cupula of the posterior semicircular canal). Because of its somewhat violent nature (and the fact that most patients with BPV are elderly), the author does not advocate its use but includes it to be complete.

As in the side-lying test, the patient sits on the edge of the gurney with the head turned opposite to the involved side. The patient is brought rapidly down onto his or her side (this serves to dislodge the otoliths off the cupula). The patient is then rapidly brought to the other side, maintaining the head in the same position (so the patient's face will be facing the gurney). The patient is then brought to the original sitting position. See the video below.

Neurologic consultation is indicated for cases of positional vertigo and nystagmus that do not satisfy criteria for BPV. For example, downbeat nystagmus usually indicates a central cause. Although downbeat nystagmus can also indicate anterior canal involvement (which is benign), this is extremely rare.