How can vomiting be managed in patients undergoing the Epley maneuver for Benign Paroxysmal Positional Vertigo (BPPV)?

Managing Vomiting During the Epley Maneuver for BPPV

Nausea and vomiting are common side effects of the Epley maneuver that should be managed with pre-procedural counseling and prophylactic medication when necessary, rather than avoiding this highly effective treatment for BPPV.

Understanding the Problem

• The Epley maneuver (canalith repositioning procedure) is the first-line treatment for posterior canal BPPV, with significantly higher success rates (around 80% with 1-3 treatments) compared to medication alone 1, 2
• Nausea and vomiting are recognized complications that occur in approximately 12% of patients undergoing the Epley maneuver 1
• These symptoms are caused by the movement of otoconia (calcium carbonate crystals) through the semicircular canals during the repositioning procedure 1

Pre-Procedure Management

• Before performing the Epley maneuver, counsel patients that they may experience sudden onset of intense subjective vertigo with possible nausea and vomiting that will typically subside within 60 seconds 1
• Warn patients about the falling sensation that may occur within 30 minutes after the maneuver 1
• Identify patients at higher risk for severe nausea/vomiting:
  • Those with history of motion sickness
  • Patients who experienced severe nausea during diagnostic Dix-Hallpike testing
  • Elderly patients with more severe BPPV symptoms 2

During-Procedure Management

• Ensure proper positioning and support throughout the maneuver to minimize excessive movement that could exacerbate symptoms 1
• Maintain each position in the sequence for the recommended 20-30 seconds, allowing time for symptoms to subside before moving to the next position 1
• Move slowly between positions if the patient reports severe nausea 1
• Consider pausing briefly between position changes if nausea becomes severe 1

Prophylactic Medication Options

• For patients with history of severe nausea or who experienced significant nausea during Dix-Hallpike testing, consider prophylactic anti-emetic medication before the procedure 2
• The American Academy of Otolaryngology-Head and Neck Surgery guidelines suggest that vestibular suppressant medications may be considered for short-term management of severe autonomic symptoms like nausea or vomiting in severely symptomatic patients 2, 3
• Potential options include:
  • Prochlorperazine for short-term management of severe nausea/vomiting associated with the procedure 2
  • A single dose of meclizine 25-50mg administered 1 hour before the procedure may be considered for prophylaxis in patients with severe symptoms 2

Important Cautions

• Vestibular suppressant medications should only be used for short-term symptom management and not as definitive treatment for BPPV 2, 3
• These medications can cause significant side effects including drowsiness, cognitive deficits, and increased fall risk, especially in elderly patients 2, 3
• Long-term use of vestibular suppressants can interfere with central compensation in peripheral vestibular conditions 3
• There is one reported case of hemorrhagic stroke following the Epley maneuver in a 77-year-old patient with severe nausea and vomiting, though this is considered extremely rare and does not warrant changes to standard practice 4

Modified Approach for High-Risk Patients

• For patients with severe symptoms or who failed previous attempts due to vomiting:
  • Consider using the modified Epley maneuver, which prolongs the time in the healthy side lying position and final bowing position, potentially reducing symptom severity 5
  • This modified approach has shown higher first-attempt success rates (85% vs 63%) and reduced canal switching compared to the traditional Epley maneuver 5
• If multiple attempts are needed, space them appropriately to allow recovery from symptoms 6

Follow-Up Recommendations

• Reassess patients within 1 month after initial treatment to document resolution or persistence of symptoms 2, 3
• If symptoms persist, consider repeating the Epley maneuver, as multiple sessions may be required for complete resolution 6
• Discontinue any prescribed vestibular suppressants as soon as possible after successful repositioning 2, 3

Alternative Approaches

• For patients who cannot tolerate the Epley maneuver despite medication, consider alternative repositioning procedures such as the Semont liberatory maneuver 1, 7
• The Semont maneuver has similar success rates to the Epley maneuver but involves different movements that may be better tolerated by some patients 7