BPPV, and those who experienced only vertigo without nystag-
mus were labeled as having subjective BPPV. A complete neuro-
tological history and examination were performed on all patients.
When deemed appropriate, audiogram, electronystagmography,
evoked response audiometry, and imaging studies were per-
formed to rule out other disease processes.
After diagnosing BPPV on Dix-Hallpike testing, patients
received the Semont liberatory maneuver. This consists of placing
the patient in the seated position in the middle of the examina-
tion table. With the patient’s head rotated 45° away from the
affected side, the patient is rapidly laid back onto a side-lying
position on the examination table. The head is maintained in a
turned position 45° away from the affected side for 5 minutes.
After 5 minutes the patient is rapidly moved en bloc to the
opposite side-lying position, maintaining the original head align-
ment. This position is maintained for 5 minutes. After 5 minutes
the patient is slowly moved to a sitting position. Patients are
given instructions to sleep at an upright (Ͼ45°) position and to
avoid bending, looking up or down, or other head movements for
24 hours.
(89%) than did the placebo group (27%). Steenerson et
al.14 studied 40 patients with BPPV who were randomly
assigned into treatment with Epley maneuvers versus
vestibular habituation exercises as compared with 20 pa-
tients who declined treatment. All patients treated with
Epley maneuvers or vestibular habituation were symptom
free or significantly improved after 3 months, whereas
only 25% of the control group were symptom free or sig-
nificantly improved after 3 months.
Further randomized studies have failed to demon-
strate substantial difference in efficacy between the vari-
ous maneuvers. Herdman et al.,15 in 1993, evaluated the
modified Epley maneuver verses Semont maneuver in a
randomized study of 60 patients. The authors found an
improvement in 90% of patients in both groups and con-
cluded that both single-treatment procedures are effec-
tive. Cohen et al.16 compared three randomized groups
(modified Epley maneuver, modified Epley maneuver with
augmented head rotations, and modified Semont maneu-
ver); all groups had significant decreases in vertigo inten-
sity and frequency with no significant differences detect-
able between groups.
The interpretation of these studies is complicated by
the variable and nonuniform maneuvering techniques and
reporting of results, such as the definition of a positive
result, the actual methods or modifications to the de-
scribed procedures, the use or nonuse of mastoid oscilla-
tion, the adherence to strict instructions after the proce-
dure, the number of procedures performed, and the time
course of therapy. As such, one person’s cure may be
another person’s failure.
Patients were re-evaluated in the clinic at 3 weeks’ time.
Patients who failed to report for follow-up were contacted by
telephone to record their subjective results. Treatment was
graded as “complete” if there were no subjective complaints of
vertigo, “partial” if there was significant improvement but per-
sistent vertigo of nonpositional nature, or “failure” if there re-
mained a subjective complaint of positional vertigo and/or find-
ings of nystagmus on Dix-Hallpike positioning. Thus, responses
were gauged both by physician’s examination and patient report-
ing. Recurrences were defined by any return of vertigo or wors-
ening of a much improved vertigo after an initial improved re-
sponse (usually after a 4- to 6-week period after treatment).
2
Comparisons between groups were made using testing with
significance noted for P Ͻ.05.
In addition to our patients who have objective BPPV,
we have noticed a subset of patients who experience posi-
tional vertigo on Dix-Hallpike testing who do not demon-
strate positional nystagmus observable to the examiner
with the unaided eye. The vertigo in this subset of patients
was described as similar to that of patients who have
objective BPPV. For the purposes of the current study, we
define “objective” BPPV as the production of intense ver-
tigo with nystagmus on assuming the head position of
Dix-Hallpike testing, usually lasting 5 to 10 seconds after
a several-second latency. “Subjective” BPPV is defined as
the production of the same type of vertigo as classic BPPV
on Dix- Hallpike positioning, but without the observation
of nystagmus with the unaided eye (i.e., without Frenzel
lenses). Although the lack of nystagmus may prevent the
diagnosis of BPPV in the strictest sense, we have pro-
ceeded to perform Semont maneuvers on these patients.
The purpose of the current study was to evaluate the
efficacy of the Semont maneuver on patients with posi-
tional vertigo, comparing those with “objective” BPPV
(nystagmus and vertigo on Dix-Hallpike testing) versus
those with “subjective” BPPV (vertigo without nystagmus
on Dix-Hallpike testing).
RESULTS
Patient Characteristics
Of the 162 cases studied, 127 (78%) demonstrated an
objective response on Dix-Hallpike testing with nystag-
mus and vertigo (objective BPPV), whereas 35 (22%) had a
subjective response with vertigo but no observable nystag-
mus (subjective BPPV). Patient age ranged from 23 to 97
years with an average age of 56 years. One hundred
eleven patients (68%) were women and 51 (32%) were
men. The right ear was affected in 90 cases (56%), and the
left in 72 (44%). The average duration of symptoms was
115 weeks with a range from 2 days to 29 and a half years.
Objective Benign Paroxysmal Positional Vertigo
One hundred twenty-seven patients (78%) had objec-
tive BPPV (Table II). Of these, 97 patients (76%) experi-
enced total resolution of their vertigo after undergoing the
Semont liberatory maneuver and another 19 (15%) had
marked improvement. Thus, overall response for objective
BPPV was 91% (116 of 127). The average number of ma-
neuvers required before relief was obtained was 1.59. Of
the 116 patients with objective BPPV who had marked or
total relief of vertigo after the Semont liberatory maneu-
ver, 61% (71 patients) improved after the first session,
26% (30 patients) after two sessions, 10% (11 patients)
after three sessions, and 3% (4 patients) after four
sessions.
PATIENTS AND METHODS
We studied 162 patients with positional vertigo who were
referred to the senior author (D.H.) between 1997 and 1999. Pa-
tients were included if they complained of vertigo that was repro-
ducible on Dix-Hallpike testing. Patients who were observed to
have nystagmus with vertigo were labeled as having objective
Laryngoscope 112: May 2002
798
Haynes et al.: Semont Maneuver