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Patients with benign paroxysmal positional vertigo often present with recurrent symptoms of dizziness, lightheadedness, nausea, or vomiting. The following article describes the use of the Epley maneuver (or canalith repositioning maneuver) to treat benign paroxysmal positional vertigo (BPPV). This activity outlines the role of the interprofessional team in evaluating and treating BPPV with a low-cost, bedside solution. Objectives: Describe the pathophysiology of benign paroxysmal positional vertigo and the treatment with the Epley maneuver. Outline the typical presentation of patients with benign paroxysmal positional vertigo needing Epley maneuver. Review the process to properly perform the Epley maneuver. Discuss interprofessional team strategies for improving care coordination and communication to advance the proper diagnosis and treatment of benign paroxysmal positional vertigo. Access free multiple choice questions on this topic.

Whether one is a seasoned clinician or a medical student, dizziness can be difficult to diagnose and treat. It affects people of all age ranges with varying symptoms and severity. Additionally, dizziness can be difficult for patients to describe, as it can mean different things to different people. When a patient complains of “dizziness,” they could be describing vertigo, pre-syncope, balance issues, or giddiness. This difficulty in communication can result in frustration for both the patient and the provider; however, differentiating these symptoms is critical for the provider to treat the patient effectively. One critical step for providers is to characterize dizziness as “central vs. peripheral.” Dizziness can account for approximately 5% of walk-in clinics and roughly 4% of emergency department visits.[1] The differential diagnosis for dizziness encompasses numerous body systems, such as neurological, cardiovascular, or hematologic. Some studies have shown up to 15% of cases of dizziness in the emergency department are life-threatening.[1] Therefore, it is important to perform a thorough history, and physical exam, as the ultimate diagnosis can be benign or life-threatening. Symptoms and disease definitions are essential for professional communication between providers, whether they treat patients in the clinic, emergency department, or inpatient setting. The language utilized to describe terms such as ”dizziness” or ”vertigo” can often mean many different things based on one’s interpretations. Therefore, a committee was formed to promote the classification of vestibular disorders. Below are several definitions from the Committee for Classification of Vestibular Disorders to clarify these symptoms: Vertigo: A sensation of self-motion when in reality, there is no motion occurring or a perceived sense of motion during a normal head movement.[2] Dizziness: A sensation of an impaired or distorted sense of motion relative to spatial orientation.[2]

Whether one is a seasoned clinician or a medical student, dizziness can be difficult to diagnose and treat. It affects people of all age ranges with varying symptoms and severity. Additionally, dizziness can be difficult for patients to describe, as it can mean different things to different people. When a patient complains of “dizziness,” they could be describing vertigo, pre-syncope, balance issues, or giddiness. This difficulty in communication can result in frustration for both the patient and the provider; however, differentiating these symptoms is critical for the provider to treat the patient effectively. One critical step for providers is to characterize dizziness as “central vs. peripheral.” Dizziness can account for approximately 5% of walk-in clinics and roughly 4% of emergency department visits.[1] The differential diagnosis for dizziness encompasses numerous body systems, such as neurological, cardiovascular, or hematologic. Some studies have shown up to 15% of cases of dizziness in the emergency department are life-threatening.[1] Therefore, it is important to perform a thorough history, and physical exam, as the ultimate diagnosis can be benign or life-threatening. Symptoms and disease definitions are essential for professional communication between providers, whether they treat patients in the clinic, emergency department, or inpatient setting. The language utilized to describe terms such as ”dizziness” or ”vertigo” can often mean many different things based on one’s interpretations. Therefore, a committee was formed to promote the classification of vestibular disorders. Below are several definitions from the Committee for Classification of Vestibular Disorders to clarify these symptoms: Vertigo: A sensation of self-motion when in reality, there is no motion occurring or a perceived sense of motion during a normal head movement.[2] Dizziness: A sensation of an impaired or distorted sense of motion relative to spatial orientation.[2] The canalith repositioning maneuver (CRP) was coined by Dr John Epley in response to the need for non-invasive treatment for benign paroxysmal positional vertigo (BPPV).[3] Prior to the use of CRP, BPPV was often treated surgically. Following the diagnosis of BPPV, the Dix-Hallpike maneuver can localize the otolith. This manuscript will not detail how to perform the Dix-Hallpike maneuver; however, once the otolith is localized, the next step is to perform the CRP (Epley) maneuver. Of note, the endpoint of the Dix-Hallpike maneuver is the beginning of the Epley maneuver; thus, it is imperative to know how to perform both to be effective in diagnosing and treating BPPV correctly. See Figure. Epley Maneuver.

Some complications of using the technique include the inability to tolerate the quick movements needed to perform the maneuver successfully. Neck mobility requires an assessment before the maneuver. The operator should anticipate nausea and emesis; thus, premedication with an antiemetic such as ondansetron or promethazine is optional. In a Cochrane review, nausea was the most commonly cited symptom, which may cause intolerance to the procedure.[11]

The interprofessional team is vital to the treatment of BPPV while using the Epley maneuver. Though the procedure only requires one operator, the situation may require anticipation of adverse side effects to produce satisfactory care. The physician, physician assistant, or nurse practitioner performing the procedure should anticipate nausea and vomiting; thus, communication with the nursing staff is vital to ensure the patient is either premedicated with an antiemetic or has these medications readily drawn in the event the patient requires it.