The Epley Maneuver –Observations

The Epley Maneuver, as described originally by John Epley in1992 (see below) {{1}}[[1]]The Canalith Repositioning Procedure for Benign Paroxysmal Positional Vertigo. Otolaryngology Head and Neck Surgery 1992; Volume 107; 399-404. 2[[1]], is a bit more complicated than necessary. These are just some personal observations from someone who has done somewhere between 10 to 20,000 Canalith Repositioning Procedures, with well over a 90% one session success rate over the past twenty years.

We have never used any vibratory device, and we don’t worry about specific timing of each head movement. There really is no amount of time that is too long, but you just want to make sure that any moving otoconial debris has stopped moving. About one minute in each position is usually more than enough.

The article “Falling sensation in patients undergoing the Epley maneuver” may give you a sense of comfort when this happens to you. Occasionally, on having the patient sit up in the final position of Canalith Repositioning, they will experience what is known as a “Tumarkin’s Otolith Crisis”. This is more commonly referred to in our office as “totally freaking out”. Sometimes the otoconial debris, on leaving the posterior canal, will directly stimulate the utricle, giving the patient the sense that they are flying out of the chair. They will usually start screaming, waving their arms, and pitch forward or backward with all their strength. This sensation lasts just a few seconds, and is a very strong indicator that the repositioning was successful. If you can get the patient to keep their eyes open during this time period, you will typically see a burst of downbeat nysagmus. We ALWAYS hold the patient in a bear hug for a few seconds when sitting them up into the final position.

There are also occasional patients that simply can not get up and walk out of the room after repositioning. My unproven theory is that the debris may have landed on the utricle of the treated ear. In this case, we will reposition them one more time, but this time the goal is not to remove debris from the posterior canal. It is to dislodge debris from the utricle. Even the most unstable patients will improve if you just let them sit for 10 to 15 minutes after Repositioning.

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).

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

About Alan Desmond

Dr. Alan Desmond is the director of the Balance Disorders Program at Wake Forest Baptist Health Center, and holds an adjunct assistant professor faculty position at the Wake Forest School of Medicine. In 2015, he received the Presidents Award from the American Academy of Audiology.

14 Comments

  1. Kerrie:
    It is not unusual to feel a little “off” for a few to several days after undergoing the Epley repositioning procedure. Most often, the sensation subsides on it’s own. The procedure will either have worked or not after 24 hours, so we typically suggest our patients try to trigger an episode 48 hours after treatment. If you are not better, a second treatment would be in order.

  2. Hi Dr Desmond I just recently got diagnosed with bppv( in my right ear) I’ve been suffering from it for 3 weeks I saw an ENT yesterday and she did the epley manoeuvre and I feel better but still have a mild swaying feeling I’m scared to check if the manoeuvre has worked because of this feeling it’s been the worse 3 weeks ever I’m only 35 and healthy and terrified I’m stuck this way forever I just want to feel normal again will it ever pass? How ling should I wait to check if the vertigo is gone? Any info will be appreciated as Google just scares me more I’ve read all these cases of it lasting for years and don’t think I could cope with it that long. Thank you.
    Kind Regards
    Kerrie

  3. Hi Dr. Desmond-Thank you for information above. I am 41 F suffering from BPPV 3 years now. Just had latest episode and was able to do Epley and did experience what you called Tumarkin’s as I was screaming and thinking my husband and I did the maneuver incorrectly. We went to a PT 2 days after we did the maneuver as I was still foggy and could not turn my head well and thought maybe there we needed another maneuver as we didn’t get all the crystals out or they repositioned (?) into lateral canal, but he took me through a whole series of testing, etc and determined we did do the Epley correctly and could not provoke nystagmus. My question is that while I feel better (I am also on antibiotic for sinus infection), am I able to fully resume daily activities ? I feel myself keeping my head straight and trying not to turn it for fear of getting BPPV again or triggering it as well as still having some foggy sensations. I know that if it is going to happen it is going to happen, but is there ANYTHING to help prevent an occurence ? The last time I had it this bad I ended up getting it 4 times in a row and not sure why. Mine always happens when i roll over in bed from right to left but I am fearful that it will start to happen while driving, etc. Sorry for all the questions. My last one is whether the semi-canal surgical procedure is even a possibility. I can’t live with this for next 40 years, it is truly so debilitating.

  4. Obviously, when it comes to BPPV, it would be ideal to get diagnosed and treated- early on, by a qualified doctor…having said that…I came across a product (I won’t mention it by name) that is meant to aid an individual through a particle repositioning procedure- interactively. It is a small clear plastic device that clips to a baseball cap. It is filled with liquid and a little ball. The object is to wear the device while moving your head/body to move the little ball through those plastic tubes. If you know the device that I am referring to…I am wondering if you have any opinion on it’s effectiveness? For someone like myself who has been diagnosed but now has to wait for another 2 months for treatment- I am seriously thinking of giving this thing a try.

    1. The item you describe is designed to help guide your head movement through canalith repositioning. This can be accomplished just as effectively by following instructions and videos available on the web at no cost.

  5. Hi
    I got a question to ask , my doctor showed me in the past how to do the Epley at home and I feel quite confident doing it, how much of a risk do I take by doing it myself – considering the Tumarkin crisis you’ve mentioned ?

  6. Dear Dr. Alan Desmond

    excellent article , I have wanted to ask you , I am an healthy individual in general (34 yo) but I have been suffering with BPPV for more than 2 years now, my BPPV is “mild” in a sense , I don’t get too much objective vertigo , it’s more like feeling my body spins – my head rocking when i lay down , it has latency of few seconds and then lasts for 1 or 2 minutes and subsides , anyway – was not helped or treated , I booked myself an appointment with a physio for next week , just in case wanted to ask u : in the second part of the article u describe some people can’t walk after the Epley , I am a bit worried she might not be too versed with the subtle sides of it (hard to find a physio that knows too much about the condition) , is it very common ? will it resolve even if she won’t know what to do ? also – how long in your experience does it take the patient to feel better ? is it straight after the Epley or are there any side effects of dizziness once the procedure complete ? sorry for all the questions, i am a bit worried .
    Thanks

    1. Mark:
      Some unsteadiness after CRP occurs in about 5% of patients, but inability to walk happens less than 1% of the time (my observation). It is not uncommon at all to have some lingering unsteadiness and/or disorientation for a week or two after successful CRP, but the vertigo is usually resolved immediately. We ask our patients to wait 24 hrs after CRP to try and provoke an episode to see if they are better.

      1. Thank u so much for the answer Doctor Desmond , I booked the appointment for next week and really do hope it will work and won’t have to deal with too many side effects(disorientation sounds bad , I hope it’s not incapacitating0 , the internet is full of descriptions of horrors after an Epley and it made me worry although I have learnt not to trust all I see on the net , I am thankful for your experienced opinion and I wish I was around your area and would get treated by you (I live at the UK )

        Thanks: Mark

  7. Oh, I should also mention that when I did the second epley, I had what felt like two vertigo spinning in the third position (like I spun then it stopped for a split second then started again before stopping after 10 seconds or so). I’m so worried I screwed something up and moved the crystals back or just irritated the canal even more (I had the epley done by a pt a few years ago and had no more vertigo on the second epley. I’m worried though because on this most recent episode of doing the epley again I’ve had less vertigo in first position and only spun for a few seconds (I know this is a good thing), but I had more vertigo in the third position than I did the first time I did the epley, worried I’ve done something.

  8. I’ve had the epley done, but just experienced vertigo in position 1 (left bad ear. Go down a few seconds delay then the vertigo starts, stops after about 15 sec), no vertigo in position 2 (turned to right), then vertigo in position 3 (on right side facing floor), then no vertigo in position 4 (sitting back up). Is this normal? I’ve heard vertigo is invoked in all positions?

    1. Jill:
      Your description here is typical. The intense vertigo on rising (position 4) only occurs about 5% of the time.

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