The Semont-Plus Maneuver or the Epley Maneuver in Posterior Canal Benign Paroxysmal Positional Vertigo: A Randomized Clinical Study

Abstract

Importance: Questions remain concerning treatment efficacy for the common condition of benign paroxysmal positional vertigo (BPPV).

Objective: To compare the effectiveness of the Semont-plus maneuver (SM-plus) and the Epley maneuver (EM) for treatment of posterior canal benign paroxysmal positional vertigo (pcBPPV) canalolithiasis.

Design, setting, and participants: This prospective randomized clinical trial was performed at 3 national referral centers (in Munich, Germany; Siena, Italy; and Bruges, Belgium) over 2 years, with a follow-up to 4 weeks after the initial examination. Recruitment took place from June 1, 2020, until March 10, 2022. Patients were selected randomly during routine outpatient care after being referred to 1 of the 3 centers. Two hundred fifty-three patients were assessed for eligibility. After consideration of the exclusion criteria as well as informed consent, 56 patients were excluded and 2 declined to participate, with 195 participants included in the final analysis. The analysis was prespecified and per-protocol.

Interventions: After being randomized to the SM-plus or the EM group, patients received 1 initial maneuver from a physician, then subsequently performed self-maneuvers at home 3 times in the morning, 3 times at noon, and 3 times in the evening.

Main outcome and measures: Patients had to document whether they could provoke positional vertigo every morning. The primary end point was the number of days until no positional vertigo could be induced on 3 consecutive mornings. The secondary end point was the effect of the single maneuver performed by the physician.

Results: Of the 195 participants included in the analysis, the mean (SD) age was 62.6 (13.9) years, and 125 (64.1%) were women. The mean (SD) time until no positional vertigo attacks could be induced in the SM-plus group was 2.0 (1.6) days (median, 1 [range, 1-8] day; 95% CI, 1.64-2.28 days); in the EM group, 3.3 (3.6) days (median, 2 [range, 1-20] days; 95% CI, 2.62-4.06 days) (P = .01; α = .05, 2-tailed Mann-Whitney test). For the secondary end point (effect of a single maneuver), no significant difference was detected (67 of 98 [68.4%] vs 61 of 97 [62.9%]; P = .42; α = .05). No serious adverse event was detected with both maneuvers. Nineteen patients (19.6%) in the EM group and 24 (24.5%) in the SM-plus group experienced relevant nausea.

Conclusions and relevance: The SM-plus self-maneuver is superior to the EM self-maneuver in terms of the number of days until recovery in pcBPPV.

Trial registration: ClinicalTrials.gov Identifier: NCT05853328.

Figure 1.. Schematic Drawing of the Movement of the Otoconia of the Semont-plus Maneuver and Epley Maneuver for Benign Paroxysmal Positional Vertigo of the Left Posterior Canal

A, The Semont-plus maneuver includes the upright position with (1) turning of the head by 45° toward the nonaffected side; (2) movement of the body by 150° toward the affected side, which moves the otoconia further in the direction in which they should move (A toward B); (3) and since the clot is beyond the vertex (B toward C), the movement of body by 240° moves the clot into the direction (4) of the vestibulum (position D of the otoconia). B, The Epley maneuver includes upright position and (1) rotation of the head 45° toward the affected ear; (2) movement of the body backward so that the head is in a hanging position below the earth horizontal; (3) rotation of the head 90° toward the nonaffected ear; (4) rotation of the whole body downward so that the patient faces the floor and their affected ear is pointing toward the ceiling; and (5) going into the upright position while keeping a rotation of the head 45° toward the nonaffected ear, and turning the head back to the neutral position at the end. A indicates anterior semicircular canal; H, horizontal semicircular canal; and P, posterior semicircular canal.

Figure 2.. Study Flowchart

Figure 3.. Primary End Point

Histogram of days until no positional vertigo could be induced with the Semont-plus maneuver and Epley maneuver.