Semont maneuver vs Epley procedure

The authors compared the efficacy of a self-applied modified Semont maneuver (MSM) with self-treatment with a modified Epley procedure (MEP) in 70 patients with posterior canal benign paroxysmal positional vertigo. The response rate after 1 week, defined as absence of positional vertigo and torsional/upbeating nystagmus on positional testing, was 95% in the MEP group (n 37) vs 58% in the MSM group (n 33; p 0.001). Treatment failure was related to incorrect performance of the maneuver in the MSM group, whereas treatment-related side effects did not differ significantly between the groups. NEUROLOGY 2004;63:150–152 Posterior canal benign paroxysmal positional vertigo (PC-BPPV) is caused by dislodged otoconia that move within the PC whenever head position is changed. The resulting endolymph flow activates hair cell receptors, causing short-lasting vertigo and a mixed torsional/ upbeating nystagmus. This “canalolithiasis” hypothesis has been corroborated by the success of therapistguided positioning maneuvers that aim to clear the PC of trapped particles. In controlled trials, single applications of the Epley procedure1 or the Semont maneuver2 relieved 70 to 90% of patients.3-5 However, this indicates that some patients require repeated treatment until positional vertigo resolves completely. Therefore, complementary self-treatment is a desirable option to abort BPPV. We recently showed that selftreatment with a modified Epley procedure (MEP) relieved 64% of 28 patients within 1 week, whereas the Semont maneuver has not yet been evaluated for selftreatment.6 Therefore, we compared the efficacy of selftreatment with a modified Semont maneuver (MSM) and the MEP. Patients and methods. Forty-one outpatients with unilateral PC-BPPV from a dizziness clinic and 29 patients from a neurologist’s practice were included according to the following criteria: 1. History of short-lasting ( 1 minute) rotational vertigo precipitated by changes of head position; 2. A mixed torsional/upbeating nystagmus beating toward the undermost ear elicited by positional testing in the lateral or head-hanging position for 60 seconds7 as observed with Frenzel glasses; and 3. Reversal of torsional nystagmus on sitting up. Patients who had received any positioning maneuver during the acute episode of BPPV, patients with bilateral or horizontal canal BPPV, and patients who could not reliably perform selftreatment because of language problems or lack of mobility were excluded. Seventy-nine patients were eligible. After giving informed consent according to the local ethics committee, patients were randomly assigned to apply MEP (n 42) or MSM (n 37). Five patients in the MEP group and four in the MSM group were lost to follow-up. Seven of these nine patients did not return for positional testing, and two did not complete the exercise because of concurrent cardiac arrhythmia or a sore hip. Therefore, statistical analysis was performed on 70 patients (10 men, 60 women; age, 35 to 80 years [mean, 60 12 years]). The median duration of acute BPPV was 8 weeks. BPPV was idiopathic in 55 patients or occurred after head trauma (n 4) or vestibular disease (n 11). Age, sex, and mean duration of the acute episode did not differ significantly between the two groups. All patients received an illustrated instruction with their specific exercise for the affected ear (figure 1). The sequence of head and body movements was explained. Patients then performed the maneuver once under supervision of the instructing physician. Patients performed the exercise three times daily until positional vertigo had ceased for at least 24 hours. They indicated in a diary whether positional vertigo occurred during each treatment session to determine the number of sessions needed for subjective relief of vertigo and documented treatment-related side effects (e.g., nausea, gait imbalance, and dizziness). Successful treatment after 1 week was defined as absence of positional vertigo and absence of nystagmus on positional testing. Patients were asked to perform the maneuver again on their second visit to assess accuracy of treatment execution. Statistical analysis. Statistical analysis included chi-square test for dichotomous variables and Student’s t-test for continuous variables for comparison between treatment groups. Kaplan–Meier analysis, including log-rank test, was performed to test for differences in number of treatment sessions completed until positional Additional material related to this article can be found on the Neurology Web site. Go to www.neurology.org and scroll down the Table of