Evidence-Based Vertigo Treatment

Few presenting complaints are as disconcerting to patients as vertigo. Patient anxiety levels correlate highly with the degree of functional impairment. A diagnosis of benign paroxysmal positional vertigo (BPPV), the most common cause of benign vertigo, is supported by historical elements linking it with head movement and a positive Dix-Hallpike maneuver.

BPPV most commonly affects the posterior semicircular canals. The prevailing theory is that “canalolithiasis” occurs with particles moving through the canal influenced by gravity and head movement. Symptoms occur as a result of the hydrodynamic pull of endolymphatic fluid caused by stone precipitates. Symptoms tend to spontaneously resolve after an average of 39 days.

A clear diagnosis of BPPV allows us to roll into reassurance mode and provide patients with self-management techniques. Patients self-treat BPPV with the Epley maneuver. Another commonly employed technique is the Semont maneuver. 

More evidence exists regarding the efficacy of the Epley than the Semont maneuver. Dr. Ying Chen and colleagues at Changzheng Hospital in Shanghai, China, published the results of a trial evaluating the efficacy of the Semont maneuver (Otol. Neurotol. 2012;33:1127-30).

In this study, 128 patients with unilateral posterior canal benign paroxysmal positional vertigo (PC-BPPV) were randomly assigned to treatment with the Semont maneuver or sham procedure. PC-BPPV is diagnosed by observing torsion towards the lower-most ear and upbeating nystagmus. Cycles of Dix-Hallpike testing and a Semont maneuver were repeated during the treatment session until no more nystagmus or vertigo could be elicited or until 4 cycles had been completed. The sham procedure was the Semont maneuver for the unaffected side. No medications or postprocedural instructions were provided. Patients returned after four days for re-evaluation. Successful treatment was defined as absence of vertigo and a negative Dix-Hallpike test.

On the fourth day, 55 of 65 patients (85%) in the Semont maneuver group were free of vertigo and nystagmus as determined by Dix-Hallpike testing compared with 9 of 63 (14%) patients in the sham group. Forty-three percent of patients were free of vertigo after a single Semont procedure.

This study provides us with useful clinical information for patients who have unilateral BPPV with symptoms localizing to posterior semicircular canal disease. How the procedure compares to the Epley maneuver was not evaluated. The Semont procedure is easy to perform and patients can quickly be quickly trained on how to performance it. For tech-savvy patients, providing them with links to internet videos demonstrating the maneuver may be helpful.

Jon O. Ebbert, M.D., is a professor of medicine and a primary care clinician at the Mayo Clinic in Rochester, Minn. He declares having no conflicts of interest. The opinions expressed are solely those of the author. Contact him at ebbert.jon@mayo.edu.

Few presenting complaints are as disconcerting to patients as vertigo. Patient anxiety levels correlate highly with the degree of functional impairment. A diagnosis of benign paroxysmal positional vertigo (BPPV), the most common cause of benign vertigo, is supported by historical elements linking it with head movement and a positive Dix-Hallpike maneuver.

BPPV most commonly affects the posterior semicircular canals. The prevailing theory is that “canalolithiasis” occurs with particles moving through the canal influenced by gravity and head movement. Symptoms occur as a result of the hydrodynamic pull of endolymphatic fluid caused by stone precipitates. Symptoms tend to spontaneously resolve after an average of 39 days.

A clear diagnosis of BPPV allows us to roll into reassurance mode and provide patients with self-management techniques. Patients self-treat BPPV with the Epley maneuver. Another commonly employed technique is the Semont maneuver. 

More evidence exists regarding the efficacy of the Epley than the Semont maneuver. Dr. Ying Chen and colleagues at Changzheng Hospital in Shanghai, China, published the results of a trial evaluating the efficacy of the Semont maneuver (Otol. Neurotol. 2012;33:1127-30).

In this study, 128 patients with unilateral posterior canal benign paroxysmal positional vertigo (PC-BPPV) were randomly assigned to treatment with the Semont maneuver or sham procedure. PC-BPPV is diagnosed by observing torsion towards the lower-most ear and upbeating nystagmus. Cycles of Dix-Hallpike testing and a Semont maneuver were repeated during the treatment session until no more nystagmus or vertigo could be elicited or until 4 cycles had been completed. The sham procedure was the Semont maneuver for the unaffected side. No medications or postprocedural instructions were provided. Patients returned after four days for re-evaluation. Successful treatment was defined as absence of vertigo and a negative Dix-Hallpike test.

On the fourth day, 55 of 65 patients (85%) in the Semont maneuver group were free of vertigo and nystagmus as determined by Dix-Hallpike testing compared with 9 of 63 (14%) patients in the sham group. Forty-three percent of patients were free of vertigo after a single Semont procedure.

This study provides us with useful clinical information for patients who have unilateral BPPV with symptoms localizing to posterior semicircular canal disease. How the procedure compares to the Epley maneuver was not evaluated. The Semont procedure is easy to perform and patients can quickly be quickly trained on how to performance it. For tech-savvy patients, providing them with links to internet videos demonstrating the maneuver may be helpful.

Jon O. Ebbert, M.D., is a professor of medicine and a primary care clinician at the Mayo Clinic in Rochester, Minn. He declares having no conflicts of interest. The opinions expressed are solely those of the author. Contact him at ebbert.jon@mayo.edu.

Few presenting complaints are as disconcerting to patients as vertigo. Patient anxiety levels correlate highly with the degree of functional impairment. A diagnosis of benign paroxysmal positional vertigo (BPPV), the most common cause of benign vertigo, is supported by historical elements linking it with head movement and a positive Dix-Hallpike maneuver.

BPPV most commonly affects the posterior semicircular canals. The prevailing theory is that “canalolithiasis” occurs with particles moving through the canal influenced by gravity and head movement. Symptoms occur as a result of the hydrodynamic pull of endolymphatic fluid caused by stone precipitates. Symptoms tend to spontaneously resolve after an average of 39 days.

A clear diagnosis of BPPV allows us to roll into reassurance mode and provide patients with self-management techniques. Patients self-treat BPPV with the Epley maneuver. Another commonly employed technique is the Semont maneuver. 

More evidence exists regarding the efficacy of the Epley than the Semont maneuver. Dr. Ying Chen and colleagues at Changzheng Hospital in Shanghai, China, published the results of a trial evaluating the efficacy of the Semont maneuver (Otol. Neurotol. 2012;33:1127-30).

In this study, 128 patients with unilateral posterior canal benign paroxysmal positional vertigo (PC-BPPV) were randomly assigned to treatment with the Semont maneuver or sham procedure. PC-BPPV is diagnosed by observing torsion towards the lower-most ear and upbeating nystagmus. Cycles of Dix-Hallpike testing and a Semont maneuver were repeated during the treatment session until no more nystagmus or vertigo could be elicited or until 4 cycles had been completed. The sham procedure was the Semont maneuver for the unaffected side. No medications or postprocedural instructions were provided. Patients returned after four days for re-evaluation. Successful treatment was defined as absence of vertigo and a negative Dix-Hallpike test.

On the fourth day, 55 of 65 patients (85%) in the Semont maneuver group were free of vertigo and nystagmus as determined by Dix-Hallpike testing compared with 9 of 63 (14%) patients in the sham group. Forty-three percent of patients were free of vertigo after a single Semont procedure.

This study provides us with useful clinical information for patients who have unilateral BPPV with symptoms localizing to posterior semicircular canal disease. How the procedure compares to the Epley maneuver was not evaluated. The Semont procedure is easy to perform and patients can quickly be quickly trained on how to performance it. For tech-savvy patients, providing them with links to internet videos demonstrating the maneuver may be helpful.

Jon O. Ebbert, M.D., is a professor of medicine and a primary care clinician at the Mayo Clinic in Rochester, Minn. He declares having no conflicts of interest. The opinions expressed are solely those of the author. Contact him at ebbert.jon@mayo.edu.