Reader’s Choice 2014: Epley Maneuver – Observations

Christmas fir tree and decor covered with snow on wooden board backgroundDear Readers:

During this holiday season, the editors at Hearing Health & Technology Matters (HHTM) are taking some time off. However, we are not leaving you without anything to read on our blog this week. Instead, we are publishing a special holiday edition filled with what we call our Readers’ Choices.

HHTM has had more than half a million page views in 2014, and the Readers’ Choices featured this week are the posts published on each of our individual blogs that drew the largest number of viewers during the year.

Whether or not you have read these Readers’ Choice posts before, we think you will enjoy them. And be sure to return next week when all of us editors, our batteries recharged, will publish a New Year’s Eve issue filled with fascinating new posts to get 2015, HHTM’s fifth year, off to a great start.

 

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.