SGEM#108: You Spin Me Right Round Baby Like Benign Paroxysmal Positional Vertigo

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Date: February 20th, 2015

Guest Skeptics: Dr. Tony Seupaul and Dr. Chris Fowler. Tony is the Chair of the Department Emergency Medicine, University of Arkansas. Chris is a second year EM resident in Arkansas. He did his medical school in Arizona and Undergrad at Brigham Young University in Utah.

Case: 58-year-old woman with diabetes and hypertension presents with two days of feeling “dizzy”. Her symptoms worsen when she turns her head. She has also noticed that is much worse when bending over and looking up while turning her head. She has extreme nausea and has had several episodes of vomiting. She has had some improvement in her symptoms with lying flat and closing her eyes. She is very worried about something serious and asks what can be done to help with her symptoms.

Background: Benign Paroxysmal Positional Vertigo (BPPV) is a short-lived condition characterized by the sensation of rotation or instability most often exaggerated by rapid movements of the head.

The etiology is believed to be from excessive movement of fluid (endolymph) and debris within one of the three semi-circular canals of the vestibular system of the inner ear. The debris causes the fluid to continue moving after head motion has stopped giving the sensation of continued motion causing the symptoms associated with vertigo. This mechanism is called canalithiasis.

Peak incidence is between 50-70 years and affects between 11 and 67 per 100,000 each year. Symptoms often resolve spontaneously after a period of weeks but symptoms can be severe causing many to seek medical attention.

Symptoms can be provoked with the Dix-Hallpike maneuver which elicits symptoms and nystagmus. The nystagmus is torsional (superior pole of the eye directed towards the lower most ear) and up beating. There can be a latency period of up to 45 seconds with duration of less than 1 minute. Repeated positioning causes fatigue of this finding.

Once the diagnosis of BPPV is made on history and physical examination a canalith repositioning maneuver can be attempted.

It was Epley who described one of the technique used to relocate and redistribute the debris within the posterior semi-circular canal thereby eliminating symptoms. The Epley Maneuver as it is commonly called is a sequence of four head positions that use gravity to treat the BPPV or canalithiasis.

There are a number of FOAMed resources out there that demonstrate how to properly do the Dix-Hallpike and Epley maneuver.

Clinical Question: Is the Epley Manoeuvre effective in the treatment of posterior canal BPPV?

Reference: Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev. 2014

Population: 745 patients (11 RCTS) ranging from 18 to 90 years old presenting to either primary care settings or tertiary care in otolaryngology clinic with complaints of dizziness, ultimately diagnosed with BPPV by a positive Dix-Hallpike and classical features with nystagmus.
Intervention: The use of the Epley manoeuvre in treatment of posterior canal BPPV and a subsequent conversion of a positive Dix-Hallpike test to a negative test.
Comparison: RCTs evaluated looked at Epley maneuver verses placebo (sham maneuver), Epley versus control or Epley vs. other active treatment.
Outcome:
- Primary Outcome: Complete resolution of vertigo symptoms.
- Secondary Outcomes: conversion of positive Dix-Hallpike to negative; adverse side effects of treatment.

Authors’ Conclusions: “There is evidence that the Epley manoeuvre is a safe, effective treatment for posterior canal BPPV, based on the results of 11, mostly small, randomised controlled trials with relatively short follow-up. There is a high recurrence rate of BPPV after treatment (36%). Outcomes for Epley manoeuvre treatment are comparable to treatment with Semont and Gans manoeuvres, but superior to Brandt- Daroff exercises.

Quality Checklist for Therapeutic Systematic Review:

The clinical question is sensible and answerable. YES Comment: The Epley manoeuvre is generally considered a safe and simple intervention that can easily be done in a variety of settings with little to no side effects. Only patients unable to tolerate the maneuver or those with cervical spine conditions would need exclusion. The only limitation is performance of the test correctly to achieve desired results.
The search for studies was detailed and exhaustive. YES
The primary studies were of high methodological quality. YES
The assessment of studies were reproducible. YES
The outcomes were clinically relevant. YES
There was low statistical heterogeneity for the primary outcomes. NO
The treatment effect was large and precise enough to be clinically significant. YES– but confounded by the spontaneous resolution of symptoms without intervention and the subjectivity of being “symptom free”.

Key Results: Those treated with the Epley manoeuvre in pooled analysis showed a resolution of symptoms with OR of 4.42 (95% CI: 2.62 to 7.44), favoring treatment with the manoeuvre. There was also a high conversion to a negative Dix-Hallpike test in the treatment group with OR 9.62 (95% CI: 6.0 to 15.2).

The overall quality of the study is good and conforms to the standards and methods employed by other Cochrane reviews. This study is an update of previous reviews that had similar findings adding 6 new trials.

A majority of the studies included had good methods for randomization and allocation but some had problems with blinding and adequate, meaningful follow up.

Dr. Anthony Seupaul

Dr. Seupaul talks nerdy about heterogeneity. This is a rough guide to interpret heterogeneity:

0% to 40%: might not be important
30% to 60%: may represent moderate heterogeneity
50% to 90%: may represent substantial heterogeneity
75% to 100%: considerable heterogeneity

It appears that the Epley Manoeuvre does have good success in resolving symptoms and should be used more often in ED settings to treat BPPV.

One of the biggest drawbacks to the use of the Epley Manoeuvre is the time that it takes and the level of comfort that the practitioner has with the procedure.

The Epley maneuver was found to be equal to or modestly superior to other repositioning manoeuvre.

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We feel the author’s conclusions are appropriate and consistent with those of the SGEM.

SGEM Bottom Line: The Epley Manoeuvre is a safe and effective procedure that can reduce/alleviate the symptoms of BPPV in ED patients.

Dr. Chris Fowler

Case Resolution: The patient was treated with the Epley Manoeuvre and had near complete resolution of her symptoms and was discharged home with positional restrictions and ENT follow-up as needed.

Clinical Application: Treatment with the Epley Manoeuvre is an effective method of treatment for cases of BPPV.

What Do I Tell My Patient? I know you are feeling terrible. The good news is there is a safe and effective treatment for your vertigo. It is called the Epley Manoeuvre. We can do it right here in the emergency department. All it takes is you lying down on the stretcher. I move your head gently through a series of positions. This resets the problem in your inner ear and people are often 100% cured.

Keener Kontest: Last weeks’ winner was Graham Johnson from the United Kingdom. He knew Dr. Claude Beck was the first person to use defibrillation on a 14 year old both with a congenital heart abnormality during open heart surgery back in 1947.

Listen to the podcast to hear this weeks keener question. If you know the answer send me email to TheSGEM@gmail.com with “keener” or “gunner” in the subject line. The first person with the correct answer will receive a cool skeptical prize.