xRead - Episodic Vertigo (January 2026)

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426

D. LI ET AL.

Cumulative rankograms of each management at one month offollow-up

Cumulative

rankograms of each management at one week offollow-up

SUCRA value of Semont

SUCRA value of EVR

SUCRA value of QLM

SUCRA value of Hybrid

SUCRA value of Epley

0 0.2 0.4 0.6 0.8 1 1.2

0 0.2 0.4 0.6 0.8 1 1.2 0 0.2 0.4 0.6 0.8 1 1.2

0 0.2 0.4 0.6 0.8 1 1.2

0 0.2 0.4 0.6 0.8 1 1.2 0 0.2 0.4 0.6 0.8 1 1.2

0 0.2 0.4 0.6 0.8 1 1.2

65.3%

62.2%

77.5%

67.9%

65.5%

76.1%

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1 2 3 4 5 6 7 8 9

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SUCRA value of Epley

SUCRA value of EOC

SUCRA value of EAVD

SUCRA value of EVR

SUCRA value of EOC

SUCRA value of EO

0 0.2 0.4 0.6 0.8 1 1.2

57.7%

60.1%

50.4%

53.9%

55.2%

61.6%

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SUCRA value of EPR

SUCRA value of EO

SUCRA value of AVD

SUCRA value of VR

SUCRA value of EAVD

0 0.2 0.4 0.6 0.8 1 1.2

55.6%

41.6%

43.8%

40.5%

26.7%

21.9%

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SUCRA value of Sham

SUCRA value of VR

0 0.2 0.4 0.6 0.8 1 1.2

At one week of follow-up

9.53%

11.2%

24.7%

At one month of follow-up The largest value of SUCRA

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FIG. 4. Cumulative rankograms of the outcomes of each treatment graphed by SUCRA at 1 week and 1 month of follow-ups. The area under the curves indicates the possibility of rankings of treatment effects, that is, treatment with a larger SUCRA is considered to be more effective and rank first. The SUCRA of EVR is the largest at 1 week of follow-up, and the SUCRA of Semont is the largest at 1 month of follow up. AVD indicates antivertigo drug; CrI, credible interval; EAVD, Epley with antivertigo drug; EO, Epley with oscillation; EOC, Epley with only one cycle; EPR, Epley with posture restriction; EVR, Epley with vestibular rehabilitation; OR, odds ratio; QLM, quick liberatory maneuver; SUCRA, the surface area under the cumulative ranking curves; VR, vestibular rehabilitation.

PC-BPPV at 1 month of follow-up and ranked first and second, respectively. Our study showed a slight benefit of EVR over the Epley maneuver, but it was unknown if this difference was due to the addition of VR or just to the fact that the original studies that included VR as active treatment were of cohorts with reported BPPV recurrence. However, in the results of head-to-head comparisons, VR (Brandt Daroff exercises, Cawthorne-Cooksey exercises, home exercises) was not more effective than a sham maneuver or no-treatment in this meta-analysis. Therefore, we suspected that the higher recurrence rate within 1 week of PC-BPPV treatment in these original studies may be the reason for this contradiction (32). The results of our meta-analysis showed that the Hybrid (i.e., the combination of Epley and Semont maneuvers), Semont and Epley maneuvers had compa rable efficacies at the first week of follow-up. These results were in agreement with a recent consensus opin ion of the Spanish Society of Otorhinolaryngology and Head and Neck Surgery which stated that all these maneuvers were equally effective (17). In consequence, since the repositioning technique of the Hybrid maneuver is gentler than the Epley and Semont maneuvers, the

Hybrid maneuver may be the most suitable maneuver for patients with comorbidities such as vertebrobasilar insuf ficiency, cervical spondylosis, or hip function limitation, as these comorbidities may contraindicate or limit the effectiveness of the traditional maneuvers (33). The effective treatments included the EVR, Epley and Semont maneuvers at 1 week of follow-up, but only the Semont and Epley maneuvers were effective in eliminat ing nystagmus during a Dix–Hallpike test at the first month of follow-up in our meta-analysis. About 20 to 80% spontaneous resolution rate within 1 month in BPPV patients may contribute to this contradiction (12,34,35). And according to our subgroup analysis based on the symptom durations, the duration of BPPV is a potential factor that may affect the treatment efficacy. Another possible factor is the heterogeneity of the studies of Epley maneuver, many of which included several additional therapies such as vibration, medications, and repeated Epley maneuvers (versus single maneuver), etc. Finally, although our included studies were all randomized con trolled studies, the EVR was rated as low at 1 month of follow-up but moderate at 1 week of follow-up according to our GRADE evaluation, and some of the studies did not report the detail methods of randomization or

Otology & Neurotology, Vol. 43, No. 4, 2022

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