The Epley Maneuver – Observations

The Epley Maneuver, initially described by John Epley in 1992, has been widely used for the treatment of Benign Paroxysmal Positional Vertigo (BPPV). However, based on personal observations from an experienced practitioner who has performed thousands of Canalith Repositioning Procedures (CRP) over the past two decades, it appears that the maneuver may be more complex than necessary.

Despite this, the success rate of the procedure has consistently exceeded 90% in a single session.

Contrary to some approaches, no vibratory devices are used during the procedure, and precise timing of each head movement is not a major concern. The key is to ensure that any moving otoconial debris has ceased its motion, which is typically accomplished within approximately one minute in each position. This timeframe is generally sufficient for the procedure to be effective.

During the final position of the Canalith Repositioning, it is not uncommon for patients to experience what is known as a “Tumarkin’s Otolith Crisis.” This sensation, often referred to as “totally freaking out” in the practitioner’s office, occurs when the otoconial debris, upon exiting the posterior canal, directly stimulates the utricle. As a result, patients may feel as if they are suddenly propelled out of their chairs, leading to instinctive reactions such as screaming, arm waving, and forceful pitching forward or backward. While this experience lasts only a few seconds, it serves as a strong indication that the repositioning maneuver has been successful. Keeping the patient’s eyes open during this moment often reveals a burst of downbeat nystagmus. To ensure patient safety, it is customary to support them in a bear hug for a brief period after transitioning them to the final position.

Occasionally, some patients may find it challenging to stand up and walk immediately after the repositioning procedure. One speculative explanation for this difficulty is that the debris may have landed on the utricle of the treated ear. In such cases, a repeated repositioning may be performed, with the objective of dislodging debris from the utricle rather than the posterior canal. Remarkably, even the most unstable patients often show improvement simply by allowing them to sit quietly for 10 to 15 minutes following the repositioning.

These observations shed light on a simplified approach to the Epley Maneuver, challenging the need for additional techniques or strict timing protocols. By focusing on the cessation of otoconial debris movement and recognizing the unique experiences patients may encounter, practitioners can achieve high success rates while ensuring patient comfort and safety.

**Interested readers can read an update on the modified Epley maneuver here

Canalith Repositioning Procedures, as Originally Described by Epley

Epley’s (1992) original description of the CRP is as follows:

1. Preliminary—Identification of offending canal and noted latency and duration of nystagmus response

2. Preparation—Premedication with transdermal scopolamine or diazepam

3. Maneuvers—Commencement of maneuvers, changing head positions when the nystagmus response has ceased. If no nystagmus is appreciated, then an estimate of latency plus duration of previous response (typically “6 to 13 seconds”) dictates when the head is moved to the next position. Complete cycles are performed until there is no nystagmus response.

4. Oscillation—A hand-held oscillator with a frequency of approximately 80 Hz is applied to the mastoid process of the affected side.

5. Follow-up—Patients are advised to keep their head upright for 48 hours following the procedure. The CRP may be repeated weekly until the patient is asymptomatic and no nystagmus is noted in the Dix-Hallpike position (Epley, 1992).

Reference:

• The Canalith Repositioning Procedure for Benign Paroxysmal Positional Vertigo. Otolaryngology Head and Neck Surgery 1992; Volume 107; 399-404. 2.