Vertigo is a common problem in the ED. And in many cases of Benign Paroxysmal Positioning Vertigo (BPPV, also known as Benign Positional Vertigo or BPV), otolith positioning maneuvers can cure the patient, or at least make much better. While not all vertigo is BPPV, it is common enough that a procedure that takes 10 minutes and involves no needles or medications and is curative in 50-70% of cases in uncontrolled series is worth knowing.
There are several maneuvers for BPPV.
First are the Brandt-Daroff exercises, which patients can do on their own -- every 30 seconds, alternate from sitting up straight, to lying on your side with your nose up at 45 degrees, and then to lying on your opposite side with the nose pointed down at 45 degrees. Do this several times a day.
The Epley maneuver and Semont maneuver are the best-known. Many prefer the Semont, as it seems easier for elderly patients, and is easier to remember. And for the Semont, the diagnostic maneuver is the first part of the curative or liberatory maneuver. For the Semont, have the patient sitting on the edge of the cot with legs dangling, have the patient hold his or her head straight up for about 3 minutes. Then, tilt the patient over on one side, with the head down on the stretcher (this will tilt it about 30 degrees down from straight) and with the nose up at 45 degrees. If this provokes vertigo with nystagmus, after a few-second latent period ("latency"), and with gradual resolution over three minutes ("habituation"), this is the equivalent of a positive Dix-Hallpike/Nylen-Barani test.
If this doesn't work, have the patient sit straight and then tilt the patient over to the other side with the nose up at 45 degrees. If this doesn't cause vertigo, then the patient probably doesn't have BPPV.
If the Semont test is positive on either side, continue with the rest of the Semont Liberatory maneuver: after 3 minutes on the side with the nose up, flip over to the other side with the nose down. Stay here for 3 minutes. Then sit up straight for three minutes.
For those who want to learn more about these maneuvers, an outstanding reference is the textbook Vestibular Dysfunction and Its Therapy, edited by Buttner. The book is ridiculously expensive, but filled with excellent information about all types of vertigo. Just the diagrams of the Semont and Epley maneuvers is worth the price alone.
It is available from amazon.com, and also through amazon.co.uk. When Dr. Conover ordered a copy, it was cheaper from amazon.co.uk even including international shipping, and a very inexpensive paperback edition seems to be available in Europe.
The Patient Instructions page has a handout from another institution that is good for patients.