Timothy C. Hain, MD • Bart Tulicki, DPT. Page last modified: February 13, 2022
We have a lot of maneuvers named after clinicians in BPPV treatment -- Epley, Semont, Brand-Daroff, Foster, Gans. Generally speaking, there is only one way to maneuver debris out of the labyrinth, and for any particular canal within the inner ear, they all have to do exactly the same thing. So it is really all about how you maneuver the head. Some of them are easier than others. Some of them are better marketed than others.
Movie of the Semont Maneuver
The Semont maneuver, named after its inventor, Dr. Alain Semont, is another PC (posterior canal) maneuver intended to move debris or "ear rocks" (also called otoconia) out of the sensitive part of the ear (posterior canal) to a less sensitive location. It takes about 15 minutes to complete. It is also called the "liberatory" maneuver, which is meant to imply that otoconia are dislodged (i.e. knocked off) the cupula and then respositioned into the vestibule where they came from. It seems unlikely that the dislodging aspect of the maneuver happens very often, but it does incorporate the positions needed to treat loose ear rocks.
The Semont maneuver involves a procedure whereby the patient is rapidly moved from lying on one side to lying on the other (Levrat et al, 2003).
On the diagram below one starts upright (A), goes to "bad" Dix-Hallpike side (B), then one is rapidly "flipped" to "bad" side down (C), there is an optional gentle "rap" of the head against the bed, one remains there for a few minutes, and then sits back up.
The Semont maneuver is not currently favored in the United States, perhaps because the high velocity can be anxiety provoking, but it is just as effective as the favored "Epley", being 90% effective after 4 treatment sessions. Practically, it is often tried when the Epley maneuver fails.
In our opinion, it is equivalent to the Epley maneuver as the head orientation with respect to gravity is very similar. It is more efficient than the Epley in terms of total number of positions, but on the other hand, the biomechanics of the maneuver are a bit harder (but they are not as tough as the "Foster" maneuver).
While Semont thought that the rapidity of the movement between positions B and C, contributed greatly to the success of the maneuver, several models of the maneuver suggest that it contributes little to nothing (Hain et al, 2005: Obrist et al, 2016). This may be because when going from B to C above, the initial tangential acceleration acts to drive debris back into the cupula, i.e. it is counterproductive (Faldon and Bronstein, 2008). It seems unlikely though that the debris gets very far during the rapid B-C flip. Although Faldon and Bronstein noted the counterproductive acceleration vector, they suggested that speed was inded important because it resulted in higher centripetal accelerations, perhaps immobilizing the debris so it doesn't go in the wrong direction.. On the other hand, the "rap" of the head against the bed at position C may be helpful in resolving cupulolithiasis.
After the Semont maneuver, you should give patients the instructions below, which are aimed at reducing the chance that debris might fall back into the sensitive back part of the ear.
Refinements of the Semont maneuver
A recent paper by Obrist et al (2016) suggests that the head should actually best be extended beyond the horizontal by about 10 degrees, on both sides. This would of course not be possible on the bed drawn above, because to attain this position, the head would need to go off the end of the bed on both sides. However perhaps this could be done efficiently with a device designed for treatment of BPPV. Extending the head further on "B" would bring the debris a little further away from the cupula, and reduce the direction that it needs to go to "get around the turn". Extending the head further at position C might reduce the probability that debris gets "hung up" at the top of the canal, but also increase the chance of "canal conversion" into the anterior canal.
There is a home version of the Semont, which we do not recommend as in the original study, it was not very effective (Radke, 2004). The problem was that people couldn't carry it out at home.
INSTRUCTIONS FOR PATIENTS AFTER OFFICE TREATMENTS (Epley or Semont maneuvers)
1. Wait for 10 minutes after the maneuver is performed before going home. This is to avoid "quick spins," or brief bursts of vertigo as debris repositions itself immediately after the maneuver. Don't drive yourself home.
2. Sleep semi-recumbent for the next night. This means sleep with your head halfway between being flat and upright (a 45 degree angle). This is most easily done by using a recliner chair or by using pillows arranged on a couch (see figure 3). During the day, try to keep your head vertical. You must not go to the hairdresser or dentist. No exercise which requires head movement. When men shave under their chins, they should bend their bodies forward in order to keep their head vertical. If eye drops are required, try to put them in without tilting the head back. Shampoo only under the shower. Some authors suggest that no special sleeping positions are necessary (Cohen, 2004; Massoud and Ireland, 1996). We, as do others, think that there is some value (Cakir et al, 2006)
3. For at least one week, avoid provoking head positions that might bring BPPV on again.
- Use two pillows when you sleep.
- Avoid sleeping on the "bad" side.
- Don't turn your head far up or far down.
Be careful to avoid head-extended position, in which you are lying on your back, especially with your head turned towards the affected side. This means be cautious at the beauty parlor, dentist's office, and while undergoing minor surgery. Try to stay as upright as possible. Exercises for low-back pain should be stopped for a week. No "sit-ups" should be done for at least one week and no "crawl" swimming. (Breast stroke is OK.) Also avoid far head-forward positions such as might occur in certain exercises (i.e. touching the toes). Do not start doing the Brandt-Daroff exercises immediately or 2 days after the Epley or Semont maneuver, unless specifically instructed otherwise by your health care provider.
4. At one week after treatment, put yourself in the position that usually makes you dizzy. Position yourself cautiously and under conditions in which you can't fall or hurt yourself. Let your health care provider know how you did.