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BRIEF COMMUNICATIONS: A. Radtke, M. von Brevern, K. Tiel-Wilck, A. Mainz-Perchalla, H. Neuhauser, and T. Lempert Self-treatment of benign paroxysmal positional vertigo: Semont maneuver vs Epley procedure Neurology 2004; 63: 150-152 [Abstract] [Full text] [PDF]

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Self-treatment of benign paroxysmal positional vertigo: Semont maneuver vs Epley procedure

Vicente Honrubia, M.D., D.M.Sc.   (14 September 2004)

Reply to Honrubia

Andrea Radtke, Thomas Lempert   (14 September 2004)

Self-treatment of benign paroxysmal positional vertigo: Semont maneuver vs Epley procedure 14 September 2004
Vicente Honrubia, M.D., D.M.Sc., Director, Victor Goodhill Ear Ctr., Div of Head and Neck Surgery UCLA, School of Medicine, Box 951624, Los Angeles, CA 90095 Send Correspondence to journal: Re: Self-treatment of benign paroxysmal positional vertigo: Semont maneuver vs Epley procedure vh{at}ucla.edu Vicente Honrubia, M.D., D.M.Sc.	I read with interest the editorial by Furman and Hain [1] concerning the home treatment of benign paroxysmal positional vertigo (BPPV). This is also reported by Radtke et al. [2,3] The first two treatments were designed when the understanding of the mechanism of the disease was erroneous. The condition was known as cupulolithiasis, believed to result from adventitious deposits in the cupula of the posterior semicircular canal (PSC) changing the organ into a gravity sensor. Following the observations of Parnes [4], it was accepted that the pathology of BPPV consisted of the presence in the fluid of the PSC of aggregated otoconia detached from the vestibular maculae, changing the hydrodynamics of the endolymphatic fluid inside the canal. The result is an abnormal function of the crista sensory organ, albeit with different characteristics than the predicted by cupulolithiasis, and more consistent with clinical observations whereby vertigo is produced by quick head rotations only in the plane of the affected PSC, a key in the diagnosis of the condition. Epley’s article [5] concerning the canalith repositioning procedure as a treatment for BPPV provided strong evidence that particles could be extracted from the canal by rotating the patient’s head in the geometrical plane of the canal, facilitating the particle’s excursion towards the vestibule as propelled by the force of the gravitational vector upon the slug of heavier particles if executed within an appropriate time course. The success of the standard Epley maneuver for treatment of the PSC variety of BPPV has been reported as having an 88% success rate [6], and the new understanding of the pathophysiology has been shown to be theoretically correct [7,8]. Using the modified Epley maneuver, as proposed in Radtke’s paper [3] does not result in the removal of the particles from the canal. After one day of treatment, more than 80% of patients were still vertiginous (e.g., Figs. 2 of Refs. 2 and 3), raising questions about the effectiveness of the treatment as a repositioning maneuver. What is it about the modified Epley maneuver that could account for the disparity? In the standard Epley maneuver (during steps 1 and 2), the head is hanging 30-40 degrees from the horizontal plane below the plane of a hard table surface where the patient rests during the test. This is to facilitate the relocation of particles toward the distal limb of the canal (e.g., see Figs. 9-2 and 9-3 of Ref. 9). During step 3, the particles pass the zenith of the canal curvature to enter the common crux and progress away toward the vestibule where they enter during the 4th step. As illustrated in the two papers by Radtke, the angle of head extension appears to be smaller than necessary based on the well-known anatomy of the canals. More importantly, in the unsupervised home exercises, the maneuver is subject to uncontrolled errors due to either the patient’s incorrect execution (being vertiginous at the time) or to differences in accessory equipment (e.g., table, pillows.). The modified Epley maneuver obviously does not accomplish the removal of the particles from the canal as well as the standard Epley. Instead, the modified Epley represents no more than a variation of the Semont Liberatory Maneuver, a type of “shake and loose” treatment. Radtke et al should have attempted to cure the BPPV with the standard Epley when they gave the patient instructions on how to conduct the modified Epley procedure at home. It would have not taken any additional “costly and time consuming medical care.” Patients treated with maneuvers other than the standard Epley are unknowingly subjected to unnecessary daily vertiginous distress that can be avoided by correct treatment. The current understanding of the condition is that patients with BPPV of the posterior canal variety should be properly diagnosed, to avoid other coincidental vertigo provoking pathologies. They should be treated immediately with the standard Epley repositioning maneuver because it is noninvasive, quick and effective, and has minimal contraindications. Furthermore, if treatment is not successful, or there is a recurrence, the relapses do not necessarily take place in the same canal or with the same pathology and require other therapeutic procedures. [6] A follow-up visit one week after the procedure reassures the patient or allows for additional treatment if needed. There are many important questions yet to be answered about the cause of the majority of cases of BPPV. Is it due to aging, degenerative, metabolic or infectious causes? Almost half of the patients have been found to have unsuspected vestibular paresis of the horizontal semicircular canal or other inner ear maladies. [9] Is it possible to diagnose the condition in the at-risk population before the attacks occur? What therapeutic steps can be taken to avoid their recurrence? There is very limited information about the etiology and treatment of other varieties of BPPV involving the other semicircular canals. Research has to move forward on the basis of clear understanding of the advances made so far. Holding onto old concepts is not the enlightened course to follow. Endorsement of the Brandt-Daroff, Semont, or modified Epley maneuvers for unsupervised home treatment of BPPV is a disservice to patients and places them unnecessarily at risk for accidents. References 1. Furman JM, Hain TC. “Do try this at home” Self-treatment of BPPV. Neurology 2004;63:8-9. 2. Radtke A, Neuhauser H, von Brevern M, Lempert T. A modified Epley’s procedure for self-treatment of benign paroxysmal positional vertigo. Neurology 1999;53:1358-1360. 3. Radtke A, von Brevern M, TielWilck K, Mainz-Perchalla A, Neuhauser H, Lempert T. Self-treatment of benign paroxysmal positional vertigo; Semont maneuver vs Epley procedure. Neurology 2004;63:150-152. 4. Parnes LS, McClure JA. Free-floating endolymph particles: A new operative finding during posterior semicircular canal occlusion. Laryngoscope 1992;102:988-992. 5. Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal position vertigo. Otolarynogl Head Neck Surg 1992;107:399-404. 6. Honrubia V, Baloh RW, Harris MR, Jacobson KM. Paroxysmal Positional Vertigo Syndrome. Am J Otology 1999;20:465-470. 7. Honrubia V, House M. Mechanism of posterior semicircular canal stimulation in patients with benign paroxysmal positional vertigo. Acta Oto-Laryngologica, 2001; 21:234-240. 8. House M, Honrubia V. Theoretical Models for the Mechanisms of Benign Paroxysmal Positional Vertigo. Audiology & Neuro-Otology 2003;8:91- 99. 9. Baloh RW, Honrubia V. Clinical Neurophysiology of the Vestibular System. FA Davis, Philadelphia. Third Ed., 2001.
Reply to Honrubia 14 September 2004
Andrea Radtke, Charité, Berlin Augustenburger Platz 1, 13353 Berlin, Germany, Thomas Lempert Send Correspondence to journal: Re: Reply to Honrubia andrea.radtke{at}charite.de Andrea Radtke, et al.	We thank Dr. Honrubia for his critical remarks on our paper on self-treatment of BPPV. We agree with most of his arguments but do not draw the same conclusions. Cupulolithiasis is an outdated concept and current treatments should aim to clear the affected canal from mobile otoconia (canalithiasis). Both the Epley and Semont maneuvers and their modifications for self-treatment work in accordance with the canalithiasis concept even if the underlying principle may have been unknown to Semont when he developed his procedure. The Semont maneuver has been found to be equally effective as the standard Epley procedure. [1,2] The modified Epley maneuver is clearly superior to Brandt-Daroff exercises. [3] Therefore, it seems more appropriate to regard the approaches based on the Semont and the Epley maneuvers as canal-clearing procedures and not as a type of “shake and loose” treatment. The efficacy of the self-applied Epley procedure can be compromised by imprecise execution including lesser angles of head reclination which is critical for success. In addition, self- treatment with the Epley procedure appears to be less effective than the original physician-guided procedure, although no direct comparison has been undertaken at short follow-up intervals. For our study, we tested the efficacy of self-treatment alone, but as we stated, we regard the standard Epley maneuver as the first-line procedure and propose self- treatment as a complementary approach. We agree that every BPPV patient entering a doctor’s office should receive hands-on treatment and not only a sheet of paper. However, proper instruction for self-treatment may enable those patients who are not cured by a single course of a physician- guided Epley procedure, up to 30% according to several controlled studies [4,5,6], to free themselves of their BPPV before their next visit. Patients with a recurrence of BPPV should schedule an appointment for positional testing, but no harm is done when they start self-treatment in the meantime which offers them a good chance to be relieved from positional dizziness within a few days. References 1. Li JC. Mastoid oscillation: a critical factor for success in canalith repositioning procedure. Otolaryngol Head Neck Surg 1995;112:670- 675. 2. Massoud EAS, Ireland DJ. Post-treatment instructions in the nonsurgical management of benign paroxysmal positional vertigo. J Otolaryngol 1996;25:121-125. 3. Brandt T, Daroff RB. Physical therapy for benign paroxysmal positional vertigo. Arch Otolaryngol 1980;106:484-485. 4. Lynn S, Pool A, Rose D, Brey R, Suman V. Randomized trial of the canalith repositioning procedure. Otolaryngol Head Neck Surg 1995;113:712- 720. 5. Asawavichianginda S, Isipradit P, Snidvongs K, Supiyaphun P. Canalith repositioning for benign paroxysmal positional vertigo: A randomized, controlled trial. Ear, Nose and Throat Journal 2000;79:732- 737. 6. Froehling DA, Bowen JM, Mohr DN et al.. The canalith repositioning procedure for the treatment of benign paroxysmal positional vertigo: a randomized controlled trial. Mayo Clinic Proceedings 2000;75:695-700.