I am recycling a portion of a post I did a couple of years ago. This post discusses a particular observation that occurs periodically when performing canalith repositioning, namely a short burst of downbeat vertical nystagmus when bringing the patient back up to the seating position (position #4). We are revisiting this because I saw a patient last week with a very interesting nystagmus pattern after repositioning (more commonly known as the Epley Manuever). Come back next week, and I will describe the response and we will hypothesize on the possible causes.
Epley Maneuver – Observations
The Epley Maneuver, as described originally by John Epley in 1992, 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.
Photo courtesy of John Epley