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Abstract & Commentary
Source: Chang AK, et al. A randomized clinical trial to assess the efficacy of the Epley maneuver in the treatment of acute benign positional vertigo. Acad Emerg Med 2004;11: 918-924.
The study was a prospective, randomized, single-blind placebo-controlled trial of consecutive adult ED patients presenting to a university teaching hospital with benign positional vertigo (BPV). Patients were randomized to treatment with either the Epley maneuver or a placebo maneuver. Before and after the maneuvers, the severity of vertigo was evaluated on a 0 to 10 ordinal scale, which had been published previously in studies evaluating vertigo symptoms. The authors randomized 11 patients to each group before the trial was terminated based on a planned interim analysis. Inclusion criteria were: 1) a history consistent with positional vertigo; and 2) a positive Hallpike test (evocative of symptoms, nystagmus was not required). The authors excluded patients with central nervous system disease, high-grade carotid artery stenosis, unstable heart disease, severe neck disease, restricted mobility, pregnancy beyond the 24th week, vestibular neuritis, labyrinthitis, or other cause of vertigo. The vertigo created by the diagnostic Hallpike test was scored on an ordinal scale. The vertigo scale was based on the symptoms created by a side-to-side head-turning maneuver after the Epley maneuver was performed. The median decreases in vertigo severity were six (95% CI = 4 to 9) for the Epley group and one (95% CI = 0 to 3) for the placebo group (P = 0.001). The six patients in the placebo maneuver group who did not achieve a 50% improvement were treated with a rescue Epley maneuver and had improvement similar to the Epley group. The authors conclude that the Epley maneuver is a safe and effective treatment for BPV.
Commentary by Richard Hamilton, MD, FAAEM, ABMT
The Epley maneuver is a clever way to slowly move the cupulolith debris in the ampulla of the posterior semicircular canal into the less evocative region of the utriculus. We reviewed this article at our journal club meeting; it created a great deal of discussion. Physicians who have either performed an Epley maneuver on their BPV patients or have had an Epley maneuver performed on them when they had an episode of BPV greatly praised the article and encouraged others to adopt it as a standard of care. In contrast, those physicians who had less experience with the maneuver felt that the study would not change their approach. There are weaknesses in the study. The post-Epley evocative maneuver was less potent than the Hallpike and was bound to cause less vertigo, but the authors had little choice; a repeat Hallpike would cause the BPV to reoccur.
Nonetheless, I can assure you that if you do not learn and perform this maneuver in BPV patients, they eventually will get the maneuver from an otolaryngologist and be miserable until that occurs. In my opinion, this maneuver turns BPV into the "nursemaid’s elbow of the middle ear" the patient is better instantly, and the physician is rewarded instantly. Remember to discharge the patient with instructions for restricted head movements—a soft cervical collar can help with this—and to sleep sitting upright until the symptoms resolve completely. One word of caution: The Epley maneuver is only as useful as the accuracy of the original BPV diagnosis; be sure that you carefully select your patients and be certain to avoid this maneuver in patients who have posterior cerebral circulation problems. As a reminder, the Semont liberatory maneuvers can achieve the same therapeutic endpoint in patients and requires less ability to roll on one’s back. For a good description of the Epley maneuvers, see the illustration in the article taken from a prior publication.1
Dr. Hamilton, Associate Professor of Emergency Medicine, Residency Program Director, Department of Emergency Medicine, Drexel University College of Medicine, Philadelphia, PA, is on the Editorial Board of Emergency Medicine Alert.
1. Furman JM, et al. Benign paroxysmal positional vertigo. N Engl J Med 1999;341:1590-1596.