Epley maneuver

The Epley maneuver is a widely used therapeutic technique for treating benign paroxysmal positional vertigo (BPPV), particularly affecting the posterior semicircular canal. It is a non-invasive procedure that repositions displaced otoconia to relieve vertigo symptoms. Understanding its indications, mechanism, and execution is essential for effective management of BPPV.

Definition and Purpose

Definition

The Epley maneuver is a canalith repositioning procedure designed to treat BPPV by guiding displaced otoconia, also known as canaliths, from the semicircular canals back to the utricle. This restores normal vestibular function and reduces episodes of positional vertigo.

Mechanism of Action

• Canalith Repositioning: The maneuver moves loose calcium carbonate crystals that have dislodged into the semicircular canals.
• Restoration of Vestibular Function: By repositioning otoconia, abnormal endolymph flow is corrected, eliminating the inappropriate stimulation of the vestibular nerve.
• Resolution of Vertigo: Proper repositioning prevents positional nystagmus and dizziness triggered by head movements.

Indications

Primary Indications

• Posterior canal BPPV confirmed by a positive Dix-Hallpike test
• Patients experiencing brief episodes of vertigo associated with positional changes of the head

Relative Contraindications

• Cervical spine instability or severe neck pathology
• Severe cardiovascular or cerebrovascular disease
• Recent head or neck trauma
• Acute vestibular disorders not consistent with BPPV

Pathophysiology of BPPV

Otoconia Displacement

BPPV occurs when otoconia, small calcium carbonate crystals normally embedded in the utricle, become dislodged and migrate into one of the semicircular canals. The posterior canal is most commonly affected due to its anatomical orientation.

Effect on Semicircular Canals

Displaced otoconia in the semicircular canals interfere with normal endolymph flow during head movements. This abnormal flow stimulates the hair cells of the vestibular system, sending inappropriate signals to the brain and resulting in vertigo.

Triggers of Vertigo

Episodes of vertigo are typically triggered by changes in head position relative to gravity, such as rolling over in bed, looking upward, or bending forward. The duration of vertigo is usually brief, lasting seconds to minutes, and is often accompanied by nystagmus.

Clinical Presentation

Symptoms

• Sudden, brief episodes of spinning vertigo triggered by head movements
• Nausea and occasional vomiting during vertigo episodes
• Imbalance or unsteadiness when standing or walking

Signs

• Positive Dix-Hallpike maneuver reproducing vertigo and characteristic nystagmus
• Observation of torsional or upbeating nystagmus corresponding to the affected semicircular canal
• Absence of hearing loss or neurological deficits differentiating BPPV from other vestibular disorders

Procedure

Preparation

• Ensure the patient is seated on an examination table with adequate space for reclination.
• Explain the procedure to the patient and obtain informed consent.
• Assess for any cervical spine or cardiovascular limitations before initiating the maneuver.

Step-by-Step Technique

1. Have the patient sit upright with legs extended and turn the head 45 degrees toward the affected ear.
2. Quickly recline the patient to a supine position with the head hanging approximately 20 degrees below the table.
3. Maintain this position for 30 to 60 seconds or until vertigo and nystagmus subside.
4. Rotate the head 90 degrees toward the opposite side and hold for another 30 to 60 seconds.
5. Roll the patient onto their side in the direction the head is facing, with the nose pointing down, holding for 30 to 60 seconds.
6. Assist the patient to return to the seated position slowly.

Post-Procedure Care

• Advise the patient to avoid rapid head movements for several hours.
• Recommend follow-up evaluation to assess resolution of symptoms and need for repeat maneuver.
• Provide instructions for home exercises if recurrent episodes occur.

Effectiveness and Evidence

Success Rates

The Epley maneuver has a high efficacy rate, with 70 to 90 percent of patients experiencing complete resolution of symptoms after one to three sessions. Recurrence may occur in a minority of cases.

Comparison with Other Maneuvers

• Sémont maneuver: Rapid side-to-side head movements; effective for posterior canal BPPV but may be less tolerated in some patients.
• Brandt-Daroff exercises: Home-based habituation exercises; useful for recurrent or residual BPPV but slower in symptom resolution compared to Epley maneuver.

Factors Affecting Outcome

• Severity and duration of BPPV prior to treatment
• Patient adherence to post-maneuver precautions and exercises
• Presence of comorbid vestibular disorders

Complications and Safety

• Transient dizziness or vertigo immediately following the maneuver
• Nausea or mild vomiting during or after the procedure
• Neck or back discomfort due to rapid positional changes
• Canal conversion, where otoconia migrate to a different semicircular canal, potentially causing atypical vertigo
• Rare cardiovascular events in patients with underlying heart conditions

Rehabilitation and Recurrence Prevention

Home Exercises

• Brandt-Daroff exercises performed several times daily to habituate the vestibular system
• Gentle head and neck mobility exercises to maintain range of motion

Follow-Up Protocol

• Re-evaluate patients within 1 to 2 weeks after the maneuver
• Repeat the Epley maneuver if symptoms persist or recur
• Monitor for residual vertigo or nystagmus

Management of Recurrence

• Identify and treat any underlying vestibular or systemic factors contributing to recurrence
• Reapply canalith repositioning maneuvers as needed
• Educate patients on avoiding provocative positions that trigger vertigo

References

1. Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 1992;107(3):399-404.
2. Lempert T, von Brevern M. Benign paroxysmal positional vertigo and other positional vertigo syndromes. Curr Opin Neurol. 2006;19(1):41-46.
3. Bhattacharyya N, Gubbels SP, Schwartz SR, Edlow JA, El-Kashlan H, Fife T, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2017;156(3_suppl):S1-S47.
4. Fife TD, Iverson DJ, Lempert T, Furman JM, Baloh RW, Tusa RJ, et al. Practice parameter: therapies for benign paroxysmal positional vertigo. Neurology. 2008;70(22):2067-2074.
5. von Brevern M, Radtke A, Lezius F, Feldmann M, Ziese T, Lempert T. Epidemiology of benign paroxysmal positional vertigo: a population based study. J Neurol Neurosurg Psychiatry. 2007;78(7):710-715.
6. Froehling DA, Bowen JM, Mohr DN, O’Fallon WM. The canalith repositioning procedure for the treatment of benign paroxysmal positional vertigo. Mayo Clin Proc. 2000;75(7):695-700.
7. Balatsouras DG, Panagiotopoulos G, Kefalides NA, Korres GS. The role of Epley and Semont maneuvers in benign paroxysmal positional vertigo. Eur Arch Otorhinolaryngol. 2007;264(11):1309-1314.
8. von Brevern M, Lezius F, Radtke A, Heuschmann PU, Neuhauser H, Lempert T. Epidemiology of vestibular vertigo: a neurotologic survey of the general population. Neurology. 2015;85(12):1102-1111.