Otology & Neurotology 32:1008Y1011 2011, Otology & Neurotology, Inc.

Can We Predict the Efficacy of the Semont Maneuver in the Treatment of Benign Paroxysmal Positional Vertigo of the Posterior Semicircular Canal?
*Andres Soto-Varela, Marcos Rossi-Izquierdo, and *Sofa Santos-Perez
*Division of Otoneurology, Department of Otorhinolaryngology, Hospital Clnico Universitario de Santiago de Compostela, Compostela; Department of Dermatology and Otorhinolaryngology, University of Santiago de Compostela, Compostela; and Department of Otorhinolaryngology, Complejo Hospitalario de Lugo, Lugo, Spain

Objective: To establish success- or failure-predicting factors in Semont maneuver in the treatment of benign paroxysmal positional vertigo. Study Design: Prospective study. Setting: Referral center, institutional practice, ambulatory care (outpatient clinic). Patients: A consecutive sample of 135 patients diagnosed with unilateral benign paroxysmal positional vertigo of posterior semicircular canal for 3 years (September 2007 to August 2010). Intervention: Semont maneuver. Main Outcome Measures: Duration of the latency period and nystagmus status with the Dix-Hallpike test. Presence or absence of orthotropic nystagmus in the second position of the Semont maneuver. Effectiveness of the Semont maneuver (cure versus no cure). Results: The Semont maneuver is effective in 73% of the patients. Orthotropic nystagmus was present in 67% of the cases

and absent in 33%; when we found orthotropic nystagmus, the maneuver was effective in 81% of the patients, but only in 57% if this nystagmus was not present (Fishers exact test, p = 0.004; odds ratio, 3.308; 95% confidence interval, 1.492Y7.334). The maneuvers efficacy and the presence of orthotropic nystagmus were not affected by the duration of nystagmus status in the Dix-Hallpike test. The duration of the latency period had no effect on the maneuvers efficacy, but it did affect the appearance of orthotropic nystagmus (Mann-Whitney test, p = 0.016). Conclusion: The presence of orthotropic nystagmus in the second position of the Semont maneuver indicates a good prognosis, but its absence does not necessarily mean that the maneuver will fail. Orthotropic nystagmus is more common in patients with shorter latency periods, suggesting that its appearance is related to cupulolithiasis mechanisms. Key Words: Benign paroxysmal positional vertigoVCupulolithiasisVSemont maneuver. Otol Neurotol 32:1008Y1011, 2011.

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vestibular vertigo (1Y3); the posterior semicircular canal is most commonly affected (60%Y90% of all cases), and then the horizontal and, much more rarely, superior canal (3). Its treatment is fundamentally based on particle-repositioning maneuvers, aimed at removing otoconial debris from the semicircular canal to the vestibule. These maneuvers can aim at slowly and progressively repositioning the debris (with reference to the posterior semicircular canal, the Epley maneuver [4], and other derivatives), or their sudden release
Address correspondence and reprint requests to Andres Soto-Varela, M.D., Servicio de Otorrinolaringologa, Complejo Hospitario Uni versitario de Santiago, Travesa da Choupana, s/n. Postal Code: 15706, Santiago de Compostela, Spain; E-mail: andres.soto@usc.es The authors indicate that they do not have any conflicts of interest. The authors did not receive funding for this study.

(such as the Semont maneuver [5]). The former are based on the canalolithiasis theory (the particles are freely floating in the endolymph of the semicircular canal [6]) and the latter on cupulolithiasis (the otoconial debris is at least partly adhered to the cupula of the ampullar end of the canal [7]). Repositioning maneuvers are not always effective for solving the problems. Symptoms occasionally persist, requiring a repetition of the maneuver. Attempts have been made to establish whether there are predictive data that could show us when to expect a maneuver to be effective in a given patient. Specifically in relation to the Epley maneuver, it has been suggested that the orthotropic nystagmus in the second position (nystagmus with the same direction as are observed in the first position) would indicate a good prognosis and suggest that it will be effective (8). This aspect has not been specifically studied in the Semont maneuver. When the patient is turned, we 1008

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SEMONT MANEUVER AND ORTHOTROPIC NYSTAGMUS could certainly expect a nystagmus that could also be described as orthotropic (the same as in the first position of the maneuver) (5), but it has not been established whether it is a sign of a poor prognosis of the treatments effectiveness. The first objective of this study was to answer this question. On the other hand, it is difficult to distinguish between cupulolithiasis and canalolithiasis when the posterior semicircular canal is affected, as (unlike what occurs in the horizontal semicircular canal) the direction of the nystagmus is the same in both situations. Although canalolithiasis is probably the most common form when this canal is affected (9), cupulolithiasis is also possible. It has therefore been suggested that patients with cupulolithiasis would present nystagmus with a shorter latency and longer status period than those with canalolithiasis (3,10), but this has not been confirmed in recent studies (11); furthermore, the limit between the 2 situations has not been precisely defined. It is even likely that both possibilities (otoconial debris floating freely in the endolymph, but also adhered to the cupula) occur in some patients. We therefore find it interesting to analyze whether latency duration and nystagmus status are related to the efficacy of the Semont maneuver or not. This was our second objective.
TABLE 1.
Etiology Unknown ` Ipsilateral Menieres disease Trauma Ipsilateral vestibular neuronitis Serious systemic disease (cancer, transplant, etc) Ipsilateral disease of the middle ear Prior BPPV in another canal

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Etiological factors and identified associated conditions

n (%) 79 12 11 10 4 4 3 (59) (9) (8) (7) (3) (3) (2)

MATERIALS AND METHODS

In our departments treatment protocol (based on a study in which we compared the efficacy of the Semont and Epley maneuvers and the Brandt-Daroff exercises [12]), we perform the Semont maneuver on all patients diagnosed with BPPV of the posterior semicircular channel. We then verify the vertigos persistence and perform the Epley maneuver, which is repeated in the following weeks when necessary. To analyze the shortterm efficacy of the Semont maneuver and the factors that could predict its success or failure, we conducted a prospective study in 135 patients diagnosed with unilateral BPPV of the posterior semicircular canal; bilateral cases were excluded to homogenize the sample. All the participants consented to take part in accordance of the Declaration of Helsinki. The patients were diagnosed and treated for 3 years (September 2007 to August 2010, inclusive). They were 47 men and 88 women (male-to-female ratio, 1:1.9), with a mean age of 60.9 years (range, 22Y93 yr; median, 62 yr; mode, 54 yr). The right ear was affected in 78 patients (58%) and the left in 57 (42%). The mean time since onset of symptoms (included asymptomatic periods between repeated crises) was 15.9 months (minimum, 2 wk; maximum, 5 yr). The etiology was unknown in 69 patients (51%); the most ` commonly identified causes were ipsilateral Menieres disease (11 patients, 8%), trauma (10 patients, 7%), and vestibular neuronitis (9 patients, 7%); a list of the identified etiological factors can be found on Table 1. The diagnosis was established by a positive Dix-Hallpike test (DHT) in patients referring short episodes of vertigo triggered by head position changes. Typical nystagmus affecting the posterior semicircular canal (clockwise in left ears and anticlockwise in right ears) with a vertical, upward, component was an inclusion criterion. Nystagmus was observed with Frenzel spectacles; in doubtful cases, we used videonystagmography. The exclusion criteria were (a) negative DHT result (no nystagmus, even when anamnesis was consistent with BPPV), (b) superior

and/or lateral semicircular canals affected (either individually or associated to the posterior canal), and (c) bilateral posterior semicircular canal affected. On the same day of diagnosis, 1 hour after the DHT, the patients underwent the Semont maneuver, as follows: (a) when the affected ear is identified by DHT, the patient is seated on a gurney, the patients head is turned 45 degrees toward the unaffected side, and the patient is suddenly lain down on the affected side; (b) the patient is kept in this position for 4 minutes; (c) maintaining the head in the same position relative to the trunk, the patient is suddenly turned 180 degrees onto the unaffected side; (d) this position is maintained for another 4 minutes; and (e) the patient is slowly raised into a seated position. The patient was contacted a week after the Semont maneuver to find out whether the symptoms had disappeared or not; efficacy required the symptoms to have disappeared and the DHT to be negative. The following study parameters were recorded: (a) duration of latency period before the appearance of nystagmus on the DHT applied for diagnosis, (b) duration of nystagmus status on DHT at diagnosis, (c) presence or absence of orthotropic nystagmus in the second position of the Semont maneuver, and (d) resolution or not of the symptoms. The evaluation after 1 week was not performed by the same professional who performed the Semont maneuver; he/she did not know whether orthotropic nystagmus was present or absent during the maneuver. The statistical study was performed with the SPSS 15.0 program (SPSS, Inc., Chicago, IL, USA). Fishers exact test was used to analyze the relationship between the presence or absence of orthotropic nystagmus and the maneuvers efficacy and to determine the impact of sex and affected ear on its efficacy and the appearance of nystagmus. The W2 test was used to study the impact of etiological factors on the maneuvers efficacy and the presence or absence of nystagmus. Finally, the Mann-Whitney test was used to evaluate the impact of the patients age and duration of symptoms on the maneuvers efficacy or the presence of nystagmus and to establish the relationship between latency period and status duration with the maneuvers efficacy and the presence or absence of nystagmus.

RESULTS The Semont maneuver, performed once, resolved the symptoms and made the DHT result negative in 99 patients (73% of the total). Orthotropic nystagmus in the second position of the Semont maneuver was found in 91 patients (67%) but not in the remaining 44 (33%); in 1 of these 44 patients, a nonorthotropic nystagmus was observed (pure geotropic horizontal nystagmus, probably
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A. SOTO-VARELA ET AL. the Semont maneuver studied here has been reported not only in the treatment of patients with typical BPPV (15) but also in improving the symptoms in patients with subjective BPPV (sensation of vertigo in the DHT, but absence of nystagmus) (16). Our efficacy results for a single Semont maneuver (74%) are practically the same as those we obtained (73%) in a different group of patients (12), and they are within the effective range reported in the literature for a single maneuver (from 52% [17] to 90% [13]). Nonetheless, a considerable number of cases do not improve with the first maneuver and need to be subsequently repeated to resolve the symptoms. If we were able to predict, for a specific patient, that the maneuver is not going to be effective, we could perform a second maneuver during the same session (either the same or a different procedure) in an attempt to increase its efficacy. With regards to the Epley maneuver, some studies suggest that the appearance of a nystagmus in the second position, with the same direction as in the first (orthotropic nystagmus), would be a factor predicting a good outcome (8). Others, however, report that inverted nystagmus in the second position is indicative of the Epley maneuvers failure (18,19). When the Semont maneuver is being performed, it is common to find a nystagmus in the second position with the same direction as that found in the first (5). Indeed, when this is the case, the likelihood of the maneuver being effective is very high. The nondetection of this nystagmus could suggest that the maneuver will fail because it will not correctly move the otoconial debris toward the utricle. In our study, however, we found that the symptoms resolved in more than half of the patients (57%) without this nystagmus. Some of these cures could be spontaneous remissions (up to 47% are described in 1-mo follow-ups [20]). In our study, however, the evaluation took place only 1 week after the maneuver in patients who had been presenting symptoms for an average of more than 15 months. We therefore think that the number of spontaneous remissions in such a short time (1 wk) in our study population is probably minimal. Why, then, do patients without nystagmus in the second position of the Semont maneuver nonetheless present symptom relief? It could be due to otoconial debris disintegration in the first position of the maneuver, with correct displacement in the second that is nevertheless incapable of generating a sufficiently strong endolymph flow to trigger observable nystagmus. Then, the appearance of orthotropic nystagmus in the second position is a sign of a good prognosis, although the lack of such nystagmus does not mean that the maneuver will not be effective. With regard to the duration of latency and status periods, as likely indicators of cupulolithiasis (short latency period and/or long status period [10]), in our study, they are not correlated to the efficacy of the Semont maneuver. This could mean that, as other authors have already reported, the duration of these periods is not a good indicator of cupulolithiasis (11). But it could also mean that

TABLE 2. Contingency table: presence of orthotropic nystagmus versus efficacy of Semont maneuver
Orthotropic nystagmus Present Cure No cure Total 74 17 91 Absent 25 19a 44 Total 99 36 135

a One patient presented nonorthotropic nystagmus (pure horizontal geotropic).

secondary to conversion in a lateral canal BPPV). The maneuvers efficacy rose to 81% (74/91 patients) when orthotropic nystagmus was present. Otherwise, it was only effective in 57% of the cases (25/44 patients; Table 2); in 6 of these 25 patients, nystagmus was not observed in DHT, but feeling of vertigo persisted. This difference was statistically significant, with p = 0.004 in Fishers exact test (odds ratio, 3.308; 95% confidence interval, 1.492Y7.334). The Semont maneuver is therefore more likely to resolve vertigo with orthotropic nystagmus in the second position. The maneuvers efficacy was not affected by sex (Fisher, p = 0.502), age (Mann-Whitney test, p = 0.437), affected ear (Fisher, p = 0.549), etiology (W2, p = 0.646), or time since onset of symptoms (Mann-Whitney, p = 0.744). The presence or absence of orthotropic nystagmus was likewise unrelated to sex (Fisher, p = 0.379), age (Mann-Whitney, p = 0.086), affected ear (Fisher, p = 0.237), etiology (W2, p = 0.129), or time since onset of symptoms (Mann-Whitney, p = 0.835). No relationship was detected between duration of latency and status periods, analyzed separately, and the efficacy of the Semont maneuver (Mann-Whitney, p = 0.895 and 0.932, respectively). Mean duration of latency was 3.96 seconds (minimum, 1 s; maximum, 15 s); this figure was 3.95 seconds in the patients in whom the maneuver was effective and 3.97 seconds when it failed. Mean duration of status was 18.73 seconds (19.10 s if the Semont maneuver was effective and 17.69 s otherwise), with a range of 5 to 60 seconds. A relationship was found between duration of latency and orthotropic nystagmus (Mann-Whitney, p = 0.016); mean latency was shorter (3.49 s) in the patients with nystagmus that in those without nystagmus (4.90 s). No statistically significant relationship was found between duration of status and the appearance of orthotropic nystagmus or not (Mann-Whitney, p = 0.878): 18.60 seconds with orthotropic nystagmus versus 18.98 seconds otherwise. DISCUSSION Most cases of BPPV are resolved with particlerepositioning maneuvers. When the posterior semicircular canal is individually affected, the use of a specific maneuver (Epley, Semont, etc) largely depends on the clinicians experience because their effectiveness is similar, even in comparative studies (12Y14). The efficacy of
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SEMONT MANEUVER AND ORTHOTROPIC NYSTAGMUS the maneuver is equally effective in patients with either cupulolithiasis or canalolithiasis. This is supported by clinical evidence. If the Epley maneuver only resolved cases of canalolithiasis and the Semont maneuver only resolved cases of cupulolithiasis, the high success rates reported by different investigators with either maneuver (12,13,16,21,22) would not have occurred. Mixed forms (cupulolithiasis and canalolithiasis components) are probably common, and that would explain the high rate of effectiveness of the 2 maneuvers. The statistical relationship between duration of latency and the presence or absence of orthotropic nystagmus is interesting. The latency period is shorter in patients with nystagmus. This would seem to show that orthotropic nystagmus in the second position of the Semont maneuver is probably related to physiopathological situations in which there is at least a partial cupulolithiasis component. CONCLUSION (a) A single Semont maneuver effectively resolves 73% of all cases of BPPV unilaterally affecting the posterior semicircular canal. (b) Orthotropic nystagmus (of the same direction observed in the first position of the Semont maneuver) in the second position of the Semont maneuver is a sign of a good prognosis, but its absence does not necessarily mean that the maneuver is going to fail. (c) The efficacy of the Semont maneuver seems to be independent from the physiopathological mechanism that has caused the symptoms (canalolithiasis or cupulolithiasis). (d) Orthotropic nystagmus is more common in patients with shorter latency periods, suggesting that it is related to cupulolithiasis mechanisms. REFERENCES
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