Answer
B: Epley maneuver
Educational Objective
Treat a patient with benign paroxysmal positional vertigo.
Critique
The Epley maneuver should be performed in this patient presenting with symptoms of benign paroxysmal positional vertigo (BPPV). In patients with vertigo, the Dix-Hallpike maneuver can assist in distinguishing peripheral from central causes. In peripheral vertigo, the maneuver will result in nystagmus that begins after a brief period of latency (2-40 seconds) and lasts less than 1 minute. With repeated trials, the nystagmus may not be further provoked. In vertigo of central origin, the nystagmus is not associated with latency, typically lasts longer than 1 minute, and does not fatigue with repeated trials. BPPV is the most common cause of vertigo and is attributed to debris (canalithiasis), usually in the posterior semicircular canal, perturbing labyrinthine sensory receptors and resulting in the erroneous perception of angular head acceleration. BPPV is characterized by abrupt episodes of vertigo that last less than 1 minute and is provoked by a sudden change in head position. The Epley maneuver, which is performed to reposition otoliths from the semicircular canal into the vestibule, can be curative in patients with BPPV. The maneuver involves sequentially positioning the patient to encourage movement of the otoliths, and modified versions of the procedure allow patients to perform the maneuver themselves for recurrent episodes. A meta-analysis demonstrated that patients with BPPV who were treated with the Epley maneuver had significantly higher rates of improvement in symptoms compared with those who received sham treatment (odds ratio [OR] 4.4; 95% CI, 2.6-7.2).
Pharmacologic therapy for BPPV, including centrally acting antihistamines (such as meclizine), vestibular suppressants (such as diazepam), and antiemetics, may help symptoms transiently but, in general, is ineffective for long-term management or cure.
Vestibular rehabilitation therapy, when delivered by trained physical or occupational therapists, is beneficial in patients with peripheral vertigo, particularly those with recurrent or refractory symptoms; however, the initial management of this patient presenting with BPPV is to perform the Epley maneuver.
Key Point
Benign paroxysmal positional vertigo can be effectively treated with the Epley maneuver, which is performed to reposition otoliths from the semicircular canal into the vestibule of the ear.
Bibliography
Kim JS, Zee DS. Clinical practice. Benign paroxysmal positional vertigo. N Engl J Med. 2014 Mar 20;370(12):1138-47. [PMID: 24645946]
Venue
Ambulatory Care