In some patients with BPPV, one treatment is not enough to resolve all symptoms. Which maneuver is best for the second treatment?
Benign paroxysmal vertigo (BPPV) is the most common cause of vertigo with a lifetime prevalence of 2.4%. Treatment is also relatively straightforward as the Epley and Semont maneuvers are the best options with high success rates. The difficulty lies in precisely identifying and specifying the type of BPPV and channel involved.
The simplest assessment for BPPV was based on a good subjective history, followed by a Dix-Hallpike maneuver for confirmation. Symptoms often include dizziness lasting around 60 seconds, caused by a change in position, nausea, and visual disturbances, which can occur before syncope formation. The Dix-Hallpike is shown in the following video.
There was never a clear consensus as to which between Epley and Semont is more effective. The comparison is poorly researched and the frequency of the maneuvers in clinical practice is very different. This is especially true for persistent symptoms that do not respond to the first treatment.
Learn more about the vestibular anatomy
Recent findings from systematic reviews show that repeated Epleys in people with persistent symptoms impaired the symptoms after the first maneuver. The same was found for repeated Semont movements. But what about combined treatments like an Epleys followed by Semont and vice versa?
A new study was published to investigate whether alternating Epley and Semont maneuvers are more effective than repeating the same maneuver in resolving persistent posterior BPPV positional nystagmus.
Methods
This was a retrospective analysis of the results of patients with posterior BPPV with a second maneuver for persistent symptoms.
Participants were excluded if no symptoms occurred after a single maneuver, if bilateral or multi-channel BPPV was present, if the participant had previously had problems with BPPV, neck movements, or if there were signs of neurological, mental health or forms the central channel conditions.
The vestibular examination was carried out before and 15 minutes after the treatment using video nystagmography. The diagnosis was confirmed by the presence of optimistic torsional nystagmus caused by the Dix-Hallpike movement. All participants have completed the Dizziness Handicap Inventory.
The movements used for the dream tent are shown below. All patients were followed up 1 month after treatment, where video nystagmography and DHI were again performed.
A total of 182 patients were included in the retrospective analysis. Total:
47 patients were treated with two Semont maneuvers ( ST Group )
64 were treated with two Epleys ( EP Group )
71 were treated with Epleys and then with Semont ( EP-ST Group )
Epley's maneuver
In this study, the researchers used a modified Epley, which is described as:
The patient was placed in an upright position with head 45 turned toward the affected ear.
The patient was then quickly returned to a supine
position.
Next, the head was rotated 90 ° towards the unaffected side (19459012).
After this rotation, the head was rotated a further
90 in the direction of the unaffected ear, rolling the trunk to the
unaffected side.
Each position was held for approximately 1 minute. The patient was then placed in an upright sitting position to complete the maneuver.
Semont maneuvers
For the Semont maneuver:
The patient sat in an upright position and the patient's head was rotated around the unaffected side.
The patient was then quickly moved to a lateral position on the affected side.
Next, the patient was quickly moved to the opposite side lying position without changing the head orientation.
Each position was held for approximately 2 minutes. Then the patient was brought into the upright sitting position.
Clinical implications and clinical takeaway
In summary, seeing a patient with persistent symptoms of benign paroxysmal positional vertigo in the posterior region and performing an Epley maneuver first is probably the best course of action. Perform a semont after the Epley or repeat the Epley. . Repeated semonts do not appear as an effect.
Brief summary of the results of this retrospective analysis
EP-ST was more effective than repeated ST
EP-ST was as effective as repeated EP
No significant difference in the DHI values for any of the results
At the 1-month follow-up examination only 12 patients (6.6%) had persistent symptoms
It is important to keep in mind that this is a retrospective analysis which limits the full study of the data, however the data it contained were homogeneous, which means an effective statistical analysis. Future and larger studies are needed to determine which between Epley and Epley followed by Semont is more effective for treating persistent symptoms.
