Posterior Canal BPPV Pre- and Post-Epley Maneuver

𝗢𝗿𝗶𝗴𝗶𝗻𝗮𝗹 𝗗𝗲𝘀𝗰𝗿𝗶𝗽𝘁𝗶𝗼𝗻: This is a patient with typical right posterior canal benign paroxysmal positional vertigo (BPPV), which was provoked by the Dix-Hallpike maneuver. When the patient was moved into the right Dix-Hallpike maneuver, after a brief latency, upbeat-torsional (towards the lowermost or affected [right] ear) nystagmus was seen. The patient was then treated with an Epley maneuver (see https://collections.lib.utah.edu/details?id=187680 for an example), and was later rechecked with the right Dix-Hallpike maneuver. At that point, the maneuver did not provoke nystagmus and vertigo, demonstrating that the Epley maneuver had been successful in moving the otoconia out of the right posterior canal. Examination features in this case that reassure the examiner that they are dealing with BPPV (as opposed to a central positional nystagmus variant) include the following: fatigability (not shown here, but with repetitive Dix-Hallpike maneuvers, the vertigo and nystagmus become less and less prominent); a brief latency between Dix-Hallpike and the onset of vertigo/nystagmus (as the otoconia moves to the most dependent part of the canal during Dix-Hallpike, it drags the endolymph with it, and this endolymph flow deflects the cupula causing vestibular excitation - because deflection of the cupula does not occur instantaneously during the Dix-Hallpike, a brief latency is the consequence); a crescendo-decrescendo nystagmus; the expected pattern of nystagmus is observed given the laterality of the specific Dix-Hallpike maneuver performed (e.g., right Dix-Hallpike produces nystagmus with an upbeat component and with a torsional component, with the top poles beating towards the lowermost/affected [right] ear); vertigo and nystagmus respond to properly performed repositioning (Epley or other) maneuvers. 𝗡𝗲𝘂𝗿𝗼-𝗼𝗽𝗵𝘁𝗵𝗮𝗹𝗺𝗼𝗹𝗼𝗴𝘆 𝗮𝗻𝗱 𝗡𝗲𝘂𝗿𝗼-𝗼𝘁𝗼𝗹𝗼𝗴𝘆 𝗧𝗲𝘅𝘁𝗯𝗼𝗼𝗸 𝗟𝗲𝗴𝗲𝗻𝗱: When the patient was moved into the right Dix-Hallpike maneuver, after a brief latency, upbeat-torsional (toward the lowermost or affected [right] ear) nystagmus was seen. The patient was then treated with an Epley maneuver, and was later rechecked with the right Dix-Hallpike maneuver. At that point, the maneuver did not provoke nystagmus and vertigo, demonstrating that the Epley maneuver had been successful in moving the otoconia out of the right posterior canal. Examination features in this case that reassure the examiner that they are dealing with BPPV (as opposed to a central positional nystagmus variant) include the following: fatigability (not shown here, but with repetitive Dix-Hallpike maneuvers, the vertigo and nystagmus become less and less prominent); a brief latency between Dix-Hallpike and the onset of vertigo/ nystagmus (as the otoconia moves to the most dependent part of the canal during Dix-Hallpike, it drags the endolymph with it, and this endolymph flow deflects the cupula causing vestibular excitation- because deflection of the cupula does not occur instantaneously during the Dix-Hallpike, a brief latency is the consequence); a crescendodecrescendo nystagmus; the expected pattern of nystagmus is observed given the laterality of the specific Dix-Hallpike maneuver performed (e.g., right Dix-Hallpike produces nystagmus with an upbeat component and with a torsional component, with the top poles beating toward the lowermost/ affected [right] ear); vertigo and nystagmus respond to properly performed repositioning (Epley or other) maneuvers https://collections.lib.utah.edu/ark:/87278/s6s79d1w. (Video courtesy of Dr. Marco Mandala)