sinaiem.org

At last, videos of the Dix-Hallpike and Epley maneuvers are discussed, in video form — via McGraw-Hill’s AccessMedicine website (where Tintinalli is also online). Maybe this will cut down on their interchangeability in clinical parlance! Since the audio is horrible, EM Practice has a nice description of the Dix-Hallpike test from their 2001 Dizziness issue (see below):

…the Dix-Hallpike maneuver (sometimes called the Nylen-Bárány, Bárány, Nylen, or Hallpike maneuver), involves moving the patient rapidly from sitting to a position of head hanging with one ear downward, and then repeating the test with the other ear. When positive, the patient will, after a 1- to 5-second latency period (or longer), complain of a sensation of rotational vertigo, accompanied by nystagmus. The nystagmus tends to be vertical and rotatory, “the upper pole of the eye beating toward the dependent ear and the vertical nystagmus beating toward the forehead.” While vertical nystagmus is “bad” (indicating a central lesion) if it occurs during gaze testing, vertical nystagmus is “okay”(indicating a peripheral lesion) if it occurs in the context of the Dix-Hallpike maneuver.

The vertigo and nystagmus resolve within 50 seconds of onset. Nystagmus may recur after the patient returns to the seated position, but this time its direction is reversed. If the nystagmus induced by the Dix-Hallpike maneuver does not fit this description, the patient may have central vertigo. The Dix-Hallpike maneuver was positive in 7%-44% of patients complaining of dizziness. In patients with BPPV, however, the sensitivity of the maneuver increased to 50%-88%, suggesting that this maneuver is likely to be useful only in patients who complain of vertigo. Repetition of the maneuver leads to a reduction in the intensity of vestibular symptoms. The patient who displayed such prominent vertigo and nystagmus after the initial maneuver may have a much less impressive response when you return with your colleagues to demonstrate your findings!

The Epley Maneuver, and its limitations, is described as well:

After confirming the diagnosis, therapy for BPPV is centered on repositioning the inner ear crystals to prevent recurrence of symptoms. This can be achieved via a bedside maneuver introduced by Epley in 1992. The canalith repositioning maneuver, often called the Epley maneuver, involves a series of head-positioning maneuvers that allow the floating particulate matter in the posterior semicircular canal to pass into the utricle, thereby eliminating abnormal vestibular input and improving symptoms. This maneuver is described in the accompanying diagram. Repetition of the procedure is recommended for patients not experiencing relief after the initial maneuver. Epley reported an 80% success rate after a single treatment session and a 100% success rate after more than one session. Other attempts to replicate Epley’s success rate have measured success rates ranging from 44% to 88%. A randomized trial of the Epley maneuver vs. untreated controls showed 89% success in the treatment arm and 23% in the control arm. Presumably, this procedure can also be performed in an ED setting, although no ED success rates have been reported. Vestibular rehabilitation exercises consisting of repetitive side-to-side head movements performed while lying down should be provided as part of the discharge instructions for patients with BPPV. They have been shown to be very effective in reducing the need for return ED visits for recurrent symptoms. However, even with treatment, Epley reported a 30% recurrence rate over a 30-month period.

Posted on Monday, August 18th, 2008 at 6:15 pm by Nick. Filed under Physical Exam, Blog.
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