What to do after the epley maneuver? Is your patient cured?

[@julesbruchez-theartofgrapp9646]

Amazing when I watched your video to the end. Exactly what I was treated for horizontal canal issues. I have bad equilibrium in my family. I think because we have large ear canals. It’s almost like I have supersonic hearing my whole life. I can hear things better than others, but I was worn though that we can get vertigo easier. At age 47 now I retired MMA fighter after thousands and thousands of concussions now I suffer from vertigo. But it was the horizontal Maneuverthat my PT figured out that’s what I needed. You were the first video on KZbin that I found that shows it.

[@ConfidentialEncrypted]

This gave me the most information I have ever been able to find. I wish I could see this doctor. If I don’t get this level of care, I will go see this dude.

[@PeterJohns]

Thanks. I am no longer in clinical practice. Still active in vertigo education for medical professionals though.

[@CollinRodgers-z1n]

Great video. Good to have material that informs folks what to do after performing the Epley Maneuver. That appears to be lost on majority of those I’ve seen posted.

[@benjaminpang3575]

Thank you so much. I used this information to film my own eye movements during DHT and treated myself. After 1 Epley maneuver the 2nd DHT was negative. Your videos have helped innumerable people around the world. We thank you good sir.

[@Mjzzz11]

Hi Dr.Johns, I performed 2 epley manuevers on a 76 yo pt after he had a fall and became dizzy at home when getting out of bed. He stated that his vertigo lasted for about 8 sec. I performed the DHT and sure enough he was positive. Thanks you for all of your great info and patient examples.

[@VampMastaFOBOS]

Thank you! I always do the roll test on both sides after sucsessful epley manuver to ensure that there is no additional horizontal canal bppv

[@vee9133]

This video is the best! Wry needed for all medical professional who help patients with vertigo

[@Tagmose89]

Hi Peter ! As always great and concise content with important nuances to edge us all towards improving patient care in this group of patients ! No specific comments for this video other than (balancing 101 Vs 201 approaches to dizziness) maybe adding cupolithiasis and talking about other aftercare measures to tell patients - risk of relapse - the (dis)use of antihistamins / benzoes - Other non-specific rehabilitation methods for the patients like Brandt-Daroff (especially when you can’t seem to find the right channel or it’s cupolithiasis) - The advice on “movement is good / keep moving” in a safe way despite the dizziness . No matter the cause it will improve All the best Peter

[@hyojinkim8885]

Thank you Dr. Johns. This contents is good for neurologist.

[@madslouispetersen8204]

I usually re-test with the whole epley maneuver, so im sure that there is not part of the movement that still cause dizziness, and the patient feeling secure to move around again without symptoms.

[@adamborg9275]

I'm a physio working partly as consultant to the ED. I always retest the patient shortly after treatment regardless of the affected canal. I don't have time to wait 15 minutes after treatment to retest since I have have to see patients on other departments in the hospital as well. Most of the time this works well. But if it's not cured after second treatment I give them home exercises and referral to outpatient PT. Sometimes a canal switch occurs, but for me it's worth the risk. I find the most problematic patients are those presenting with persistent apogeotropic horizontal canal BPPV (cupulolithiasis). These patients have low success rate in my experience in acute settings. Funny enough i tend to see the horizontal canal BPPVs much more than the posterior canal BPPVs!

[@PeterJohns]

I've been lucky that I've always been able to convert a apogeo to geo with the Gufoni maneuver. (lie on affected ear 2 mins, turn head up 45 degrees two minutes, then sit up). After that usually the Gufoni for geo fixes them. I agree that HC BPPV is quite common. I think the lack of recognition of HC BPPV is part of the reason why despite Epley describing his maneuver over 30 years ago, ED docs are still not doing it routinely. kzbin.info/www/bejne/hKPSqmx6gc6CqpY

[@adamborg9275]

Are you really sure that the apogeotropic HC-BPPVs you've seen had persistent non-paroxysmal nystagmus? It's plausible to me that the Gufoni manuever for apogeotropic HC-BPPV, followed by the standard Gufoni works well in cases of canalathiasis in the ampullary arm. But not in cases of true cupulolithiasis with persistent non-fatiguing apogeotropic nystagmus. For me it has required additional head shaking, quick repeated sidelying and sometimes prolonged rest on affected side to succeed before finally being able to cure the patient with something like a BBQ-manuever. And even this frequently fail. Maybe because some of these cases simply aren't BPPV?

[@PeterJohns]

@@adamborg9275 I'm only a page or so into this article then Igot distracted by other projects. Maybe it gives the answer. www.ncbi.nlm.nih.gov/pmc/articles/PMC10813105/pdf/brainsci-14-00015.pdf

[@adamborg9275]

Interesting paper, however discussing more the "light cupula" theory than "heavy cupula", but anyway; They do mention a study somewhere that 50% of apogeotropic HC-BPPV was cured by the Gufoni manuever, but they didn't controll for paroxysmal vs persistent nystagmus. So that could in theory very well be a strong bias to successful treatments in people with canalithiasis in ampullary arm rather than cupulolithiasis/heavy cupula. I suppose you're point was that the "heavy cupula" might share similarities in theoretical pathophysiology as in the "light cupula" (not having anything to do with loose/stuck otoconia but other factors leading to persistent cupula deflection)? Indeed if such factors exists, it's quite obvious that our repositioning manuevers, head shaking and mastoid vibration won't work because there is no otoconia in the canal to remove/reposition!?

[@aaskmelgne24]

Would you comment on two cases of the dizzy patient who has characteristic BPPV symptoms. The first without visible nystagmus on Dix Hallpike but with vertigo in the supine position. The second case is negative Dix hallpike and no vertigo in the supine position but with elicited vertigo upon returning to the sitting position. There's very little in the literature to guide management for these cases. Some studies suggest that the nystagmus is so subtle to not be visible with the naked eye and require videonystagmography to visualize, which is not available to me.

[@PeterJohns]

By supine you mean lying on back with head straight, neck not extended? And vertigo but not nystagmus in that position. And no nystagmus or vertigo in either DHT? Not sure what to makeo of that. Could be vestibular migraine, which commonly has positional dizziness. Same with second case. If a patient has neg DHT on one side (no dizziness or nystagmus), but on the other has latency of a few seconds, then develops significant dizziness that lasts from 5 to 20 seconds and then stops, but you see no nystagmus, even when you ask the patient to look towards downward and upward ear, that might be subjective BPPV. Then I would treat that side with an Epley maneuver, and repeat the DHT 15 minutes later. I've only seen this 2 or 3 times.

[@aaskmelgne24]

@@PeterJohns By supine, I mean the Dix Hallpike position with neck extended and turned laterally. Maybe it is my technique, but I see roughly equal amounts of people with dizziness w/o nystagmus on Dix Hallpike as dizziness w/ nystagmus on Dix Hallpike. I'll try asking them to look downward and upward. Sometimes I see the dizziness come on AFTER returning to the sitting position from Dix Hallpike also w/o nystagmus. I've always recommended Epley in these cases with a precaution to return if not resolved. Also adding to the challenge is that some of my patients have significant cervical spine pathology that limits neck extension.

[@VampMastaFOBOS]

By the way, would you be so kind to record a video teaching doctors how to select vestibular rehabilitation exercises for patients with different otoneurologic problems?

[@PeterJohns]

I actually don't have a good knowledge of this, so I'll stick to making videos about things I know about. Thanks for your interest.

[@harishchandergoel5159]

Great as usual 😊

[@JosephHeinecke-t5x]

Thanks doc!

[@rachelshemtov3363]

Thank you Dr. Johns! Will retest for sure!! Awesome as always

[@drj1859]

thank you very helpful

[@ronaldodeassismoreira9956]

Thank you Dr. Johns, this is a very helpful content

[@shrutisrivastava1310]

Extreme diziness gone after manever but still I feel spinny when I lay down . I had canal switch and again i had maneuver done. Two days are worst after manever.

[@ShanghaiWall]

Thanks for the video! But isn't 15 min too much? Is there any research about this? Most of the times I redo DH in about 2 min after successful Epley and it's negative

[@PeterJohns]

There has been some papers on it, but I don't think they compared 2 vs 5 vs 10 v 15. 15 minutes is probably plenty. Only waiting 2 minutes might make me concerned that instead of a cure, we are just seeing fatiguability. I don't mind them hanging around for 15 minutes in the ED. Usually by the time I see them they have been waiting hours anyway. Here is one recent study that used 5 minutes. www.frontiersin.org/articles/10.3389/fneur.2023.1328896/full I've never seen one with 2 minutes.

[@adamborg9275]

I do the same, retesting after a couple of minutes. If vertigo and nystagmus is gone when retesting after 1-2 manuevers, I find that most people are symtom free even when retesting them the following morning (if im lucky enough to be able to do that - not in the ED). So I'm not too concerned that the initial retest would be "false negative"

[@adamborg9275]

Also, I always test with the "Loaded Dix Hallpike test". Its much more sensitive than the traditional Dix Hallpike. Less likely that you'll get a false negative with the loaded Dix Hallpike!

[@PeterJohns]

@@adamborg9275 Yeah, I try and keep it simple for the vertigo novices. But I think it's great you are using it.

[@firasfattal6336]

Hello! Too many different contra verse theories about Dix hall pike test positive( pathologic) result. Should patient develop both of dizziness and nystagmus to consider it as pathologic? Or it is enough one of f them two signs? Thx

[@PeterJohns]

I have seen maybe one or two cases out of perhaps a hundred of "subjective BPPV" where the patient has neither dizziness nor nystagmus on one side, and then only dizziness and no nystagmus on the other side. And the dizziness has the appropriate latency, and duration of a regular positive DHT. Some people think it's much more common than that.

[@thomasp4436]

Hi peter, i've had difficulties with one patient. Typical BPPV history, dix hallpike negative on right side, positive on left side with typical posterior canal bppv nystagmus. Treated with epley maneuver. Tested again after 15min, dix hallpike negative. But when she was about to leave it happened again but different and more intense, mostly when looking up or down. I retested with dix hallpike still negative. On the supine roll test : nothing on the right but on the left i had rotatory nystagmus almost like a posterior canal with maybe (big maybe) geotropic horizontal component. I tried the gufoni maneuver for left ear geotropic bppv without success. It feels like it's a conversion but the nystagmus is really rotatory and not horizontal. Have you encoutered same situation? Do you think it's still posterior bppv?

[@PeterJohns]

Rotational nystagmus makes you think that you were not successful with the first Epley. I would have tried another Epley.

[@thomasp4436]

@@PeterJohns thank you for your quick answer 🙏. Yes i tried another epley but still symptomatic with dix hallpike negative. Very strange. So i gave her auto-epley maneuver to do at home, metoclopramide and will see her again in a few days. Also did you ever had posterior to anterior switch?

[@thomasp4436]

@@PeterJohns Hi peter, update on my patient. She was better a few days after but still had bppv triggered in the sagittal plane. This time dix hallpike showed vertical downward beating nystagmus. Deep-head hanging testing showed same. She was better after modified Yacovino maneuver. So it was probably a posterior to anterior switch after the first epley. Thank you very much for your videos without which i would have never been confident with vertigo. Thomas.

[@michaelgibson8402]

I'm starting to think of people have to have this procedure done all the time and they got one ear that's always causing them a problem when it makes sense just to have an occlusion done to put a stop to it