For some patients with BPPV one treatment isn’t enough to resolve all of the symptoms. For the sencond treatment which manoeuver is best to use?
Benign paroxysmal vertigo (BPPV) is the most common cause of vertigo with a lifetime prevalence of 2.4%. Treatment is relatively straightforward too with Epley’s and Semont Manoeuvers being the best options with high rates of success. The difficulty lies in the accurate identification and specifying the type of BPPV and canal involved.
The easiest way to assess for BPPV is through a good subjective history followed by a dix-hallpike manoeuvre to confirm. Symptoms commonly include dizziness lasting ~60s triggered by a change in position, nausea and visual disterbance which could be pre-syncopal. The dix-hallpike is demonstrated in the video below.
There has never been a clear consensus on which is more effective between Epley’s and Semont. Comparison is poorly researched and there is considerable variability in the number of times maneuvers are applied in clinical practice. This is particularly true for persistent symptoms which do not respond to the first treatment.
Recent evidence from systematic review shows that repeated Epleys for people with persistant symptoms after the first maneuver impoved symptoms. The same has been found for repeated Semont movements. But what about combined treatments as in an Epleys followed by Semont and vice versa?
A new study has been published with the aim to investigate if alternated Epley and Semont maneuvers could be more effective than repetition of the same maneuver in resolving persistent posterior BPPV positional nystagmus.
This was a retrospective analysis of outcomes of patients with posterior BPPV with a second maneuver for persistant symptoms.
Participants were excluded if there was an absence of symptoms after a single maneuver, if bilateral or multiple canal BPPV was present, if the participant had previous BPPV, neck movement issues or if there were any signs of neurologic, mental health or forms of central canal conditions.
Vestibular examination was performed using video nystagmography prior to and 15 minutes after treatment. Diagnosis was confirmed by the presence of upbeat-torsional nystagmus provoked by the Dix-Hallpike movement. All participants completed the Dizziness Handicap Inventory.
The movements used for the treamtent are demonstrated below. All patients were followed up at 1 month after treatment where video nystagmography and DHI were performed again.
In total 182 patients were included within the retrospective analysis. In total:
- 47 patients were treated with two semont maneuver’s (ST Group)
- 64 were treated with two Epley’s (EP Group)
- 71 were treated with Epleys then Semont (EP-ST Group)
In this study the researchers used a modified Epley’s which is described as:
- The patient was placed in an upright position with the head turned 45 toward the affected ear.
- The patient was then rapidly returned to a supine head-hanging
- Next, the head was turned 90 toward the unaffected
- Following this rotation, the head was turned by a further
90 toward the unaffected ear with the trunk rolled onto the
Each position was held for approximately 1 minute. Then the patient was brought into an upright sitting position, completing the maneuver.
For the Semont manoeuver:
- The patient was seated in an upright position and the patient’s head was turned 45 toward the unaffected side.
- Then the patient was rapidly moved to a side-lying position toward the affected side.
- Next, the patient was rapidly moved to the opposite side-lying position without changing the head orientation.
Each position was maintained for approximately 2 minutes. Then the patient was brought into the upright sitting position.
Clinical Implications and Clinical Take Home
In summary if you are seeing a patient with persistent symptoms of posterior benign paroxysmal positional vertigo and, they has an Epley manoeuver first, doing a Semont after or repeating the Epley’s is likely the best course of action. Repeated Semont’s don’t appear as effecte.
It is important to remember that this is a retrospective analysis which limits full exploration of the data however the data included was homogenous meaning effective statistical analysis. Future and larger studies are needed to establish which is more effective between Epley’s or Epley’s followed by Semont for treament of persistent symptoms.