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Vertigo - Epley manoeuvre

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Indications

Paroxysmal vertigo

and

No nystagmus (prior to assessment)

and

Upwards and rotational nystagmus on Dix-Hallpike test (diagnosing posterior canal BPPV)

Contraindications (absolute in bold)

Acute trauma

Cervical spine disease

Vascular insufficiency (carotid or vertebrobasilar)

Limited mobility

Alternatives

Rehabilitation exercises (e.g. Brandt-Daroff)

Observation (without therapeutic manoeuvres)

Informed consent

Verbal consent

Less complex non-emergency procedure with low risk of complications

Potential complications

Vertigo

Vomiting

Procedural hygiene

Standard precautions

PPE: non-sterile gloves

Area

Any bed space

Staff

Procedural clinician

Equipment

Bed with access on both sides

Positioning

Sit patient in bed, with head towards the foot of the bed

Adjust until when supine the patient’s head hangs extended 20 degrees past the end of the bed

Patients head rotated 45 degrees towards the ear to be treated

Medication

Consider ondansetron 4mg orally 30 minutes prior to procedure

Sequence

Explain the Epley manoeuvre to the patient, warning it may cause brief vertigo and nausea

Lie patient down into the positive Dix-Hallpike position

Maintain position until 30 seconds after symptom resolution

Rotate patient’s head 90 degrees until opposing ear is down (negative Dix-Hallpike position)

Maintain position until 30 seconds after symptom resolution

Ask the patient to continue to rotate the head 90 degrees by turning on their side

Maintain position until 30 seconds after symptom resolution

Return patient to the sitting position keeping the head turned towards the downward ear

Maintain sitting position for 10 minutes

Post-procedure care

Further assessment:

Repeat the Dix-Hallpike test on the positive side (repositioning successful if patient asymptomatic)

If nystagmus noted or the patient is symptomatic, repeat the Epley manoeuvre up to three times

Discharge advice:

Assess for impaired balance, falls risk and home support (if ongoing symptoms)

Educate patient on BPPV (explain pathology, possibility of recurrence, expected course)

Consider providing vestibular rehabilitation exercises (Brandt-Daroff) or instructions for the Epley manoeuvre

Suggest follow-up with either GP, ENT, neurology or vestibular physiotherapy

Tips

Performing the Epley repositioning manoeuvre quickly lowers the chances of success

Repeating the Epley manoeuvres may cure BPPV even after a failed attempt

Symptoms recur in 30%, teach the patient to perform the Epley at home

Discussion

BPPV is caused by calcium carbonate otoliths in the semi-circular canals of the inner ear. The posterior (70%) and the lateral canals (25%) are most affected by this pathology.

The Dix-Hallpike test diagnoses BPPV caused by posterior canal otoliths. Typically, after a 5-20 seconds latency, vertical upwards and rotatory nystagmus will be seen which resolves within one minute. The otoliths in the posterior canal BPPV can be repositioned by the Epley manoeuvre, which is effective with one application in 80%.

If no nystagmus or horizontal nystagmus is seen on Dix-Hallpike testing, we perform a supine roll test looking for horizontal canal BPPV. Typically, after a 5-20 seconds latency, horizontal nystagmus will be seen on testing both sides which resolves within one minute. The nystagmus will either beat towards the ground on both sides, termed geotropic nystagmus, or away from the ground, which is termed apogeotropic. The otolith in the lateral canal can be repositioned by the Gufoni manoeuvre (the Epley manoeuvre will not cure these patients).

The supine roll test and Gufoni manoeuvre may be unknown to many emergency physicians. Practice of these techniques will expand the range of BPPV you can cure in the emergency department.

Patterns of movement-initiated vertigo we cannot diagnose as posterior or horizontal canal BPPV or do not resolve with the Epley or other manoeuvres in the emergency department require specialist review (ENT, neurology or vestibular physiotherapy) or follow up to exclude rarer central causes.

Peer review

This guideline has been reviewed and approved by the following:

Emergency Care Institute

Dr Peter Johns, Assistant Professor, Department of Emergency Medicine, University of Ottawa

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

Produced with and reviewed by Dr Peter Johns, Assistant Professor, Department of emergency medicine, University of Ottawa.

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Nuti D, Zee DS, MandalĂ  M. Benign Paroxysmal Positional Vertigo: What We Do and Do Not Know. Semin Neurol. 2020;40(1):49-58. doi:10.1055/s-0039-3402733

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Dunn RJ, Borland M, O'Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

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eTG complete. Melbourne: Therapeutic Guidelines; 2017 Nov. Benign paroxysmal positional vertigo. Available from: https://tgldcdp.tg.org.au/viewTopic?topicfile=benign-paroxysmal-positional-vertigo

Sumner A. The Dix-Hallpike Test. J Physiother. 2012;58(2):131. doi:10.1016/S1836-9553(12)70097-8

You P, Instrum R, Parnes L. Benign paroxysmal positional vertigo. Laryngoscope Investig Otolaryngol. 2018;4(1):116-123. Published 2018 Dec 14. doi:10.1002/lio2.230

Omron R. Peripheral vertigo. Emerg med clin North Am. 2019;37(1):11-28. doi:10.1016/j.emc.2018.09.004

Dix MR, Hallpike CS. The pathology, symptomatology and diagnosis of certain common disorders of the vestibular system. Ann Otol Rhinol Laryngol. 1952;61(4):987-1016. doi:10.1177/000348945206100403

Kerber KA, Forman J, Damschroder L, et al. Barriers and facilitators to ED physician use of the test and treatment for BPPV. Neurol Clin Pract. 2017;7(3):214-224. doi:10.1212/CPJ.0000000000000366

NSW Agency for Clinical Innovation. Benign paroxysmal positional vertigo. Sydney: ACI; 2017 Nov. Available from: https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0003/274062/benign-paroxysmal-positional-vertigo-patient-factsheet.pdf

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