Overview of Epley Maneuver
Dizziness can be a challenging condition to diagnose and treat, whether you’re an experienced doctor or a medical student. It affects people of all ages and can range in symptoms and how severe they are. Dizziness can also be tricky for people to explain because it can mean different things to different individuals. For instance, when someone says they’re feeling “dizzy,” they could be talking about a sense of spinning (vertigo), feeling like they might faint (pre-syncope), problems with balance, or feeling lightheaded.
Understanding these symptoms is important for the doctor to treat the patients properly. To start, the doctor will try to figure out if the dizziness is coming from a problem in the brain (central) or elsewhere in the body (peripheral). Dizziness can be the reason for about 5% of visits to walk-in clinics and approximately 4% of emergency room visits.
The cause of dizziness can involve various body systems, such as the nervous system, the cardiovascular system (related to the heart and blood vessels), or the blood system (hematologic). Some research suggests that as many as 15% of dizziness cases in the emergency room are life-threatening. That’s why it’s crucial that doctors take a detailed history and do a thorough physical exam. The final diagnosis can range from not dangerous to something that could be life-threatening.
How doctors describe symptoms and diseases is vital for communication among healthcare providers, whether they treat patients in the clinic, emergency department, or a hospital. The way “dizziness” or “vertigo” are defined can mean different things depending on who you ask. That’s why a special committee was created to standardize the descriptions of disorders involving balance and dizziness. Here are some definitions they’ve made:
Vertigo: This is when you feel like you’re moving when you’re actually still, or when your head movements make you feel off balance.
Dizziness: This is when you feel like your sense of movement or position in space is off.
The canalith repositioning maneuver (CRP), also known as the Epley Maneuver, was developed by Dr. John Epley to treat a common cause of vertigo called benign paroxysmal positional vertigo (BPPV) without surgery. After diagnosing BPPV, doctors can use another method called the Dix-Hallpike maneuver to find the tiny particles causing the problem.
Although we won’t go into detail about how to perform the Dix-Hallpike maneuver, once the particles (otolith) are found, the next step is to perform the Epley Maneuver. It’s important to note that the end of the Dix-Hallpike maneuver is the start of the Epley maneuver, making it vital to know how to perform both to effectively diagnose and treat BPPV.
Anatomy and Physiology of Epley Maneuver
Benign paroxysmal positional vertigo (BPPV) is a common condition that affects the inner ear, causing feelings of dizziness or a spinning sensation known as vertigo. It’s thought to be caused by little particles known as otoliths that have moved out of place in the inner ear.
These particles are mostly found in the area known as the posterior semicircular canal, with some also found in the horizontal or lateral area. As you move your head, these otoliths are affected by gravity and shift around, which can cause your brain to receive incorrect signals that your head is moving when it’s actually still. This mismatch of information between your vestibular system (which helps with balance), your semicircular canals (which detect head movement) and your visual system (which processes what you see), results in the feeling of dizziness.
People with BPPV usually experience short bouts of spinning sensation which can be easily reproduced by certain movements.
The main cause of BPPV is often unknown, which is why it’s sometimes called ‘idiopathic’. However, it is often the only symptom present. It is worth mentioning that there’s also a connection between BPPV and other inner ear conditions like Meniere’s disease and migraines. Situations that involve head trauma or surgeries involving the inner ear can also cause BPPV. This is because these events can potentially dislodge the otoliths in the inner ear.
Why do People Need Epley Maneuver
When diagnosing benign paroxysmal positional vertigo (BPPV), or a condition causing sudden bouts of dizziness, a doctor will consider your reported symptoms and examine you. Those with BPPV often experience sudden dizziness, which can worsen with a head movement. These dizzy spells usually last less than a minute, but some people feel like it lasts longer due to ongoing nausea and balance issues.
Keep in mind, a doctor ruling that BPPV is the cause most likely means they’ve determined your dizziness is not due to more serious issues, such as a brain tumor or stroke. This is an important communication from your doctor, as many people come in worried about these severe disturbances.
Once a doctor establishes that your dizziness is due to a less severe cause, they may perform a Dix-Hallpike maneuver. This is a test where the doctor leads you through specific head movements to observe your eye reaction and confirm the BPPV diagnosis. However, if the cause of your dizziness is still uncertain, or if a issue related to the central nervous system is considered, the doctor may use other tests, such as the HiNTS exam, to further narrow down the possibilities of what’s causing your dizziness.
When a Person Should Avoid Epley Maneuver
The Dix-Hallpike maneuver is a test that doctors use to diagnose a common cause of dizziness and balance problems. However, not everyone can safely undergo this test. If a person has certain health conditions like neck problems or a narrow spinal canal in their neck (cervical spinal stenosis), they might not be able to do the fast actions and movements this test requires.
Even some doctors may hesitate to use this test or the Epley maneuver (another test for balance problems). A small study of 50 emergency doctors found that some were less likely to use these tests because of past negative experiences, forgetting how to do the test, or preferring to diagnose the condition based on the patient’s description of symptoms. However, most doctors reported positive experiences using these maneuvers.
Equipment used for Epley Maneuver
The essential equipment you will see includes:
- An Examination table
Additionally, there might be some optional equipment and materials such as:
- Equipment to set up an intravenous line, which is simply a quick way to deliver medication or fluids directly into the body.
- Medication to prevent nausea and vomiting (also known as antiemetics), such as ondansetron, promethazine, or meclizine, might be given.
- A bag for you to throw up in if you start to feel sick (emesis bag).
- A pillow placed under your shoulders to tilt your head backwards (hyperextension of the neck).
Receiving antiemetics before the Epley maneuver (a technique used to treat a common cause of dizziness and balance problems) can make you feel more comfortable and temporarily reduce any feelings of nausea and sickness that can sometimes be associated with this procedure.
Who is needed to perform Epley Maneuver?
The Epley Maneuver is a procedure that can be done by one person, such as a doctor or nurse practitioner. There can also be other nurses standing by in case the person doing the procedure needs help in repositioning you, the patient.
Preparing for Epley Maneuver
Before beginning a specific treatment called the Epley Maneuver, doctors typically use another technique known as the Dix-Hallpike maneuver. This helps them figure out exactly where the small crystals called canaliths are located in the inner ear. This procedure often assumes that these canaliths are in the right inner ear, but if they’re in the left ear, the steps are simply performed in reverse.
A pillow may be placed on the bed to comfortably let the patient’s head stretch out beyond a flat, or horizontal, position. To get started, the patient sits straight up on the examination table. Meanwhile, the doctor will be standing right behind the patient, near the top end of the bed where the patient’s head is.
How is Epley Maneuver performed
In this process, the doctor will gently turn your head about halfway to your right shoulder and quickly lay your head back over the edge of the examination table. Following this, they’ll observe your eyes to check for a rapid, involuntary movement, known as ‘torsional nystagmus’. You should remain in each position for at least half a minute.
As your eye movements get better, it signals that the tiny stones or crystals (also called otoliths) in your inner ear, which help manage your body’s balance and spatial orientation, are moving into a better position for the following steps of the process.
Next, your head will be turned quickly about a quarter turn further to your left, and again, you’ll be asked to hold this position for at least 30 seconds. Afterwards, you’ll be instructed to rotate your entire body and head to the left side, with your head turned so that you’re looking downwards and a bit so you can see the floor.
Finally, the doctor will help you to sit up from lying down, while keeping your head in the same downward-facing position. Depending on your response to the process, the doctor may need to repeat these steps if necessary.
Possible Complications of Epley Maneuver
There are instances where a person may find it challenging to swiftly perform the technique due to complications. Before even trying the technique, it’s important to check if the neck is flexible enough. Also, the procedure could lead to feelings of nausea or vomiting. To manage this, the person can take an optional anti-sickness medication like ondansetron or promethazine. According to a review by the Cochrane organisation, which is a trusted source of scientific reviews, the most common side effect was indeed nausea, which could make some people not able to carry out the procedure.
What Else Should I Know About Epley Maneuver?
The Epley maneuver is an easy, low-cost, and safe treatment option for a condition called benign paroxysmal positional vertigo (BPPV), which causes dizziness. This straightforward method can be done right by the patient’s bed, whether at a clinic or in the emergency room. A review by a respected medical research group called Cochrane found that patients who did the Epley maneuver were more likely to see their symptoms improve compared to those who didn’t. So, if you have BPPV, the Epley maneuver could be a great solution for you.
