To clear debris from both the anterior and posterior canal, the Modified Epley maneuver can be performed. 

 

Posterior Canal:  Begin technique with affected ear in dependent position.  

 

Anterior Canal:    Theories exist proposing that it may be efficatious to perform the Epley in reversed for the anterior canal, beginning with the non affected ear in the dependent position. This method has not been thoroughly validated, however it may yield beneficial results (Herdman, S.J., 2007).  

 

Described below is a modified technique, as the original Epley called for decreased time in each position (Herdman, S.J. 2007).

 

Position 1:

1:  Begin with the patient positioned in long sitting on a treatment table (Picture A).
2:  Have the patient rotate their head 45 degrees towards the affected ear (in the case of anterior canal, patient begins with head rotated towards the non-affected ear).
3:  Support the patient's head, maintaining 45 degrees of rotation and quickly lower them into supine with 30 degrees cervical extension (Picture B)

4:  Maintain this position until nystagmus resolves, plus an additional 30 seconds.  The patient's involved ear should be facing downward.



Position 2:

5:  Slowly rotate the patient's head 90 degrees, so the involved ear is facing upward and the uninvolved ear is facing the table. Maintain this position until nystagmus resolves plus an additional 30 seconds (Picture C and D).

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Position 3:

1:  Support the patient's head, and instruct them to roll onto the side they are currently facing.  The goal is to position the patient's head so it is facing directly down at the table.     

2:  When the patient is facing directly downward, instruct him or her to tuck their chin.  In this position, the involved canal is facing directly downward and debris are released from the canal.  If desired, you may tap behind the involved ear to assist in clearance. Hold this position until nystagmus resolves plus an additional 30 seconds (Picture E). 

3.  Bring patient's legs off the edge of the table.  Instruct him or her to keep the chin tucked and head rotated.   Slowly return to upright sitting.  Make sure you are near the patient, as patient's will sometimes feel symptomatic and require support to keep from falling backwards.

4.  Allow the patient to slowly return to comfortable sitting.  





Evidence:

Posterior Canal:

"The cochrane review identified a statistically significant effect in favor CRP compared with controls (Bhattacharyya et al., 2008)."  Overall, the Epley appears to be a highly effective method for treatment of posterior canal BPPV. 





Mastoid Oscillation:  Herdman, S. J., 2007 states that debris may not always move through semicircular canals smoothly.  A canal jam may occur, blocking endolymph movement, preventing the displacement of the cupula.  Mastoid oscillation may be a way to facilitate debris through the canal, and prevent adherence to the walls of the semicircular canals.  Currently, the evidence does not yet recognize this condition or technique (Hain TC, et al., 2000; Sargent et. al., 2001)

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Neck extension:  It is important to have adequate neck extension (30 degrees) when performing this technique for the posterior canal.  Due to the position of the canal, there is risk for conversion from posterior canal to horizontal canal when adequate neck extension is not maintained between position 1 and position 2.