Emergency Department Care
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, 5]
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 approximately 80%. When it fails, it is the author's experience that it is either being incorrectly applied to patients with vestibular neuritis or labyrinthitis, or that the patient raised his/her head too high in the 3rd part of the Epley maneuver, in which the patient rolls onto the side and looks towards the ground.
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. [6]
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 4 mg IV ondansetron (Zofran).
Epley maneuver steps
Have the patient sit upright on the gurney with the head turned 45° to the affected side. Recall that the affected side 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.
Epley maneuver. Move the patient back in the gurney such that when he lies down, his or her head will hang over the edge of the gurney. Emphasize to the patient to keep his or her eyes open during each position so that nystagmus can be observed. Lower the guardrails of the gurney on the opposite side from which the patient's head is turned.
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.
Epley maneuver. Turn the patient's head 45° to the side that had the most prominent symptoms during the Hallpike test. In this example, the patient's head is turned 45° to the left. With both hands holding the patient's head, gently lay the patient down in the supine position with the head hanging over the edge of the bed. Note: Each maneuver does not need to be performed rapidly. The Epley maneuver is positional, not positioning.
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.
Epley maneuver. Guide the patient's head down so that he or she is looking at the ground. Again, wait for at least 30 seconds.
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.
Epley maneuver. The patient's head needs to be regripped again. Then, the patient needs to sit up with the legs hanging over the side of the gurney (which is why the guardrails need to be lowered before the start of the procedure).
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.
Consultations
Neurologic consultation is indicated for cases of positional vertigo and nystagmus that do not satisfy criteria for BPV. For example, downbeat (fast phase beating towards the feet) nystagmus is more likely to indicate a central cause of vertigo as opposed to peripheral vertigo caused by anterior semicircular canal involvement, the latter of which is extremely rare.
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Anatomy of the semicircular canals.
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Epley maneuver. Move the patient back in the gurney such that when he lies down, his or her head will hang over the edge of the gurney. Emphasize to the patient to keep his or her eyes open during each position so that nystagmus can be observed. Lower the guardrails of the gurney on the opposite side from which the patient's head is turned.
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Epley maneuver. Turn the patient's head 45° to the side that had the most prominent symptoms during the Hallpike test. In this example, the patient's head is turned 45° to the left. With both hands holding the patient's head, gently lay the patient down in the supine position with the head hanging over the edge of the bed. Note: Each maneuver does not need to be performed rapidly. The Epley maneuver is positional, not positioning.
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Epley maneuver. The patient's head should be at 45° and hanging off the edge of the bed. Observe the patient's eyes and look for torsional nystagmus. Keep the patient in this position for at least 30 seconds or until the nystagmus or symptoms resolve.
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Epley maneuver. Because the patient's head will be turned 90° in the other direction, the physician needs to move to the head of the gurney and regrip the patient's head so that the fingers are pointing toward the patient's feet.
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Epley maneuver. Turn the patient's head 90° in the opposite direction (in this case, the patient's head is now facing to the right). Again, observe for nystagmus and hold this position for at least 30 seconds or until nystagmus or symptoms resolve.
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Epley maneuver. Close-up view of step shown in Media file 6.
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Epley maneuver. Ask the patient to turn onto his or her shoulder.
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Epley maneuver. Guide the patient's head down so that he or she is looking at the ground. Again, wait for at least 30 seconds.
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Epley maneuver. Close-up of view shown in Media file 9.
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Epley maneuver. The patient's head needs to be regripped again. Then, the patient needs to sit up with the legs hanging over the side of the gurney (which is why the guardrails need to be lowered before the start of the procedure).
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Epley maneuver. The patient is now sitting upright.
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Epley maneuver. Move the patient's head slightly forward. This completes the Epley maneuver. The maneuver may be performed multiple times.
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Hallpike test. In this example, the right posterior semicircular canal is being tested. Note that the head extends over the edge of the gurney. The thumb can be used to help keep the eyelids open since noting the direction of the nystagmus is important.
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Epley maneuver. In this example, the left posterior semicircular canal is being treated. In this clip, the maneuvers are performed quickly. In a real patient, each position should be held for at least 30 seconds or until resolution of the nystagmus and vertigo.
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Semont maneuver. Generally reserved for the cupulolithiasis form of benign positional vertigo, in which the otoliths are attached to the cupula of the semicircular canal. This maneuver has to be performed rapidly to be effective, and it is not recommended in elderly persons. In this example, the right posterior semicircular canal is being treated.
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Bar-b-que maneuver. This maneuver is used to treat horizontal canal benign positional vertigo. In this example, the right horizontal canal is being treated. Each position should be held at least 20-30 seconds.
