What is the proper procedure for performing an Eply maneuver?

Epley Maneuver: Proper Procedure

The Epley maneuver (canalith repositioning procedure) is performed through a specific 5-step sequence of head positions, each held for 20-30 seconds, designed to move displaced otoconia from the posterior semicircular canal back into the vestibule using gravity. 1

Step-by-Step Procedure

Initial Positioning

• Position the patient upright with the head turned 45° toward the affected ear (the ear that tested positive on Dix-Hallpike testing) 1

Step 1: Supine Head-Hanging Position

• Rapidly lay the patient back to a supine position with the head hanging 20° below horizontal 1
• Maintain this position for 20-30 seconds 1

Step 2: First Head Turn

• Turn the head 90° toward the unaffected (opposite) side while maintaining the supine position 1
• Hold for approximately 20 seconds 1

Step 3: Body Roll to Lateral Decubitus

• Turn the head an additional 90° in the same direction (total 180° from starting position) 1
• This requires the patient's body to move from supine to lateral decubitus position 1
• The patient's head should be nearly face-down at this point 1
• Hold for 20-30 seconds 1

Step 4: Return to Upright

• Bring the patient back to an upright sitting position, completing the maneuver 1

Mechanism and Efficacy

The maneuver works by utilizing gravity to move free-floating otoconia (canalithiasis) through the alignment of the posterior semicircular canal back into the vestibule, thereby eliminating the pathologic stimulus producing vertigo in BPPV 1

Patients treated with the Epley maneuver have a 6.5-times greater chance of symptom improvement compared to controls (OR 6.52; 95% CI 4.17-10.20) and similar likelihood of converting to a negative Dix-Hallpike test (OR 5.19; 95% CI 2.41-11.17) 1

Clinical Context and Indications

• The Epley maneuver is specifically indicated for posterior canal BPPV confirmed by positive Dix-Hallpike testing 1
• This procedure can be performed by most trained clinicians in various healthcare settings without specialized equipment 1
• The Dix-Hallpike test must be performed first to identify the affected ear before proceeding with the maneuver 1

Important Caveats

Complete symptom resolution is significantly less likely (37% vs 86%) in patients with additional vestibular pathology beyond BPPV, even though the maneuver remains equally effective at resolving positional nystagmus 1

Patients with atypical nystagmus, suspected additional vestibular pathology, failed response to the maneuver, or frequent BPPV recurrences may warrant comprehensive vestibular function testing 1