Brilliant. I’ve been using the hints exam. With such a litigation heavy culture, I’m assuming that if documented this would prevent legal trouble out of the gate ? Has that ever been tested?
There is no doubt in my mind that if someone were to document the findings that I outlined in this video, that it would be very strong evidence that the examiner did a very through and thoughtful evaluation. And really, writing a good medico-legal chart is is simply performing a good evaluation and documenting that you did so. I am not aware of any published papers that looked at the ability of any approach to vertigo with regards to preventing a lawsuit.
Thanks Peter for all your efforts. STANDING uses spontaneous nystagmus as indication to do parts of HINTS for AVS. You add nystagmus at rest , which also adds nystagmus at 30 degrees of L/R gaze. Do you think STANDING should / could incorporate your definition of nystagmus at rest? If I had a patient with paroxysmal, episodic vertigo that sounds like BPPV, and not like AVS, but had some horizontal nystagmus at 30 degrees - would you not do a DH test? Or Would you do a HINTS? 😊
You are asking a very nuanced questions. I like that! Adding nystagmus at rest will not pick up many cases of VN, but some. Vanni (STANDING) also advocate using frenzel glasses, which I don't think is necessary, but would probably pick up spontaneous nystagmus in those cases. About those that sounds like BPPV, but have some nystagmus at 30 degrees eccentric gaze. They might have VN which is resolving, and only get symptomatic when they make a large head movement. So if I saw horizontal nystagmus on one side at 30, I'd do the HINTS on them and the DHT. This is one of the only times I would suggest that both the DHT and HINTS should be done, and the reason why is that's it's fairly rare, and if a vertigo novice decided to routinely do HINTS and DHT on all dizzy patients, they would be torturing VN patients and getting falsely concerned a stroke on the BPPV patients. The thing about both HINTS and STANDING is that they both imply that the history is secondary and the bedside tests are primary. I disagree. Asking a careful history of what has been happening, and asked about central features is very important. Thanks for the question!
@@PeterJohns thanks Peter - your videos and your responses are impressive and oh so helpful. I don’t recall ever being able to ask an expert about those grey cases like this. Cheers mate
Hahaha! . I actually have cured my brother and also a emergency resident of posterior canal BPPV at a teaching session in the past. Also cured two physicians while they were working in the ED.
Hey, can you do a video outlining the pearls in differences of posterior horizontal and anterior canal BPPV and the relative frequencies? Or as well as the maneuvers to treat them. they’re in prior videos, but it’s hard to access on demand. Maybe include a chart
Someone asked: "Am I to understand that practically all stroke patients presenting with vertigo have spontaneous nystagmus? What do I do with patients who report persistent vertiginous symptoms (i.e. acute vestibular syndrome) but zero nystagmus and no other neurological findings (e.g. ataxia, diplopia)? Consider it as stroke if the HIT is normal? " For the answer, watch this video at this time stamp. ua-cam.com/video/MgzhbsxzBdA/v-deo.html
Doc, why the vertical vor and torsional arent frequently tested like the horizontal? And one more question if you let me, why the torsional vor has different behavior depending on the speed of head tilt. For example, if the head is tilted very fast to the shoulder, the eyes will have many quick torsional movements to the same side of head tilt, but if the head is move very slowly to the same position there are way less quick torsional eye movements or even none quick torsional eye movements. Thanks
The reason why the head impulse test (HIT) is horizontal is because almost all patients with vestibular neuritis have horizontal nystagmus. Only around 2% of patients with VN will have it affect the inferior portion of the vestibular nerve only. These patients with inferior vestibular neuritis will have vertical nystagmus which is beating away from the forehead. Someone trained in how to use the head impulse test in that direction would come in handy. I am not that person. I'm not sure I can give you a good answer about the second question. I am a retired emergency physician with a keen interest in teaching others how to evaluate vertigo, but I am not a an expert in all things related to vertigo.
@@PeterJohns doc, your answer was brilliant as always. Just one more question, I was curious about the vor with eyes closed and after doing researches it says that it works in total darkness and with eyes closed. In my experience, I noticed that when moving the head to the left with eyes closed, after fixating on a target, my eyes doesn’t move behind my eyelids at all but move right before opening the eyelids, differently from the right side that the eyes moves behind the eyelids. Does the vor actually work with eyes closed, and is it possible/ does it means something to have an asymmetric vor with eyes closed?
Great videos, they helped me a lot! Just out of curiosity, how do you film while doing the head impulse test, do you have a second person holding the phone or do you have some kind of phone mount? ;)
I have a relative or someone who is working with me hold the camera. Important that they know to turn the flash on, get close enough to include both eyebrows and several inches of forehead and nose in the video.
@@PeterJohns thanks for the quick reply, that‘s what I thought, I think the videos are a great tool for documentation and teleaching but it‘s not always easy to do if there‘s no one around to help
@@LukasDearing I did try once having the patient hold the phone. I placed a piece of tape on phone in the middle for them to focus on, had the flash on and I ensured the phone was the right distance and framing, then reach over them to do the HIT. A big awkward, but worked!
hi doctor, just clarifying when you say constant dizziness, do you mean dizziness that isn't just positional dependent like in BPPV, or do you mean dizziness always, all day (as these seems very unlikely for a patient to have).. Thank you!
Yes, the patient population who benefits from the HINTS exam are having either vestibular neuritis or posterior circulation stroke presenting with dizziness. Both those patient populations endorse having many hours or days of constant dizziness, which is worsened with head movements, but not brought on by head movements as BPPV is. In my emergency medicine practice, this kind of constant dizziness lasting all day was not unusual, and most had vestibular neuritis.
What do you want to know about it? Not unusual after a had injury, and often involves multiple canals or both ears. Treat the most symptomatic one first, then then treat what's left after that.
Absolutely amazing . Straight to the point and clear explanations
This is by far the best vertigo resource anywhere. Amazing content!
Best ever explanation!
Thank you! This video is easy to understand and informative.
Fantastic and excellent as always Peter, love your content
Brilliant. I’ve been using the hints exam. With such a litigation heavy culture, I’m assuming that if documented this would prevent legal trouble out of the gate ? Has that ever been tested?
There is no doubt in my mind that if someone were to document the findings that I outlined in this video, that it would be very strong evidence that the examiner did a very through and thoughtful evaluation. And really, writing a good medico-legal chart is is simply performing a good evaluation and documenting that you did so. I am not aware of any published papers that looked at the ability of any approach to vertigo with regards to preventing a lawsuit.
❤❤❤love your presentation as always ❤❤❤
Thanks Peter for all your efforts.
STANDING uses spontaneous nystagmus as indication to do parts of HINTS for AVS. You add nystagmus at rest , which also adds nystagmus at 30 degrees of L/R gaze. Do you think STANDING should / could incorporate your definition of nystagmus at rest?
If I had a patient with paroxysmal, episodic vertigo that sounds like BPPV, and not like AVS, but had some horizontal nystagmus at 30 degrees - would you not do a DH test? Or Would you do a HINTS? 😊
You are asking a very nuanced questions. I like that!
Adding nystagmus at rest will not pick up many cases of VN, but some. Vanni (STANDING) also advocate using frenzel glasses, which I don't think is necessary, but would probably pick up spontaneous nystagmus in those cases.
About those that sounds like BPPV, but have some nystagmus at 30 degrees eccentric gaze.
They might have VN which is resolving, and only get symptomatic when they make a large head movement. So if I saw horizontal nystagmus on one side at 30, I'd do the HINTS on them and the DHT. This is one of the only times I would suggest that both the DHT and HINTS should be done, and the reason why is that's it's fairly rare, and if a vertigo novice decided to routinely do HINTS and DHT on all dizzy patients, they would be torturing VN patients and getting falsely concerned a stroke on the BPPV patients.
The thing about both HINTS and STANDING is that they both imply that the history is secondary and the bedside tests are primary. I disagree. Asking a careful history of what has been happening, and asked about central features is very important.
Thanks for the question!
@@PeterJohns thanks Peter - your videos and your responses are impressive and oh so helpful. I don’t recall ever being able to ask an expert about those grey cases like this. Cheers mate
Don’t wanna brag but… Dr Johns performed the hallpike test on me during the Eusem congress last year. Just kidding. I actually wanted to brag
Hahaha! . I actually have cured my brother and also a emergency resident of posterior canal BPPV at a teaching session in the past. Also cured two physicians while they were working in the ED.
Hey, can you do a video outlining the pearls in differences of posterior horizontal and anterior canal BPPV and the relative frequencies? Or as well as the maneuvers to treat them. they’re in prior videos, but it’s hard to access on demand. Maybe include a chart
Hmm.....I'll put that on my to do list. Unfortunately, that list is pretty long at the moment.
Someone asked: "Am I to understand that practically all stroke patients presenting with vertigo have spontaneous nystagmus? What do I do with patients who report persistent vertiginous symptoms (i.e. acute vestibular syndrome) but zero nystagmus and no other neurological findings (e.g. ataxia, diplopia)? Consider it as stroke if the HIT is normal? " For the answer, watch this video at this time stamp. ua-cam.com/video/MgzhbsxzBdA/v-deo.html
Thank you very much We use it in Turkiye
that was clear and concise
Doc, why the vertical vor and torsional arent frequently tested like the horizontal? And one more question if you let me, why the torsional vor has different behavior depending on the speed of head tilt. For example, if the head is tilted very fast to the shoulder, the eyes will have many quick torsional movements to the same side of head tilt, but if the head is move very slowly to the same position there are way less quick torsional eye movements or even none quick torsional eye movements. Thanks
The reason why the head impulse test (HIT) is horizontal is because almost all patients with vestibular neuritis have horizontal nystagmus. Only around 2% of patients with VN will have it affect the inferior portion of the vestibular nerve only. These patients with inferior vestibular neuritis will have vertical nystagmus which is beating away from the forehead. Someone trained in how to use the head impulse test in that direction would come in handy. I am not that person. I'm not sure I can give you a good answer about the second question. I am a retired emergency physician with a keen interest in teaching others how to evaluate vertigo, but I am not a an expert in all things related to vertigo.
@@PeterJohns doc, your answer was brilliant as always. Just one more question, I was curious about the vor with eyes closed and after doing researches it says that it works in total darkness and with eyes closed. In my experience, I noticed that when moving the head to the left with eyes closed, after fixating on a target, my eyes doesn’t move behind my eyelids at all but move right before opening the eyelids, differently from the right side that the eyes moves behind the eyelids. Does the vor actually work with eyes closed, and is it possible/ does it means something to have an asymmetric vor with eyes closed?
@@guilhermenunes8460 No idea. I've never tested the VOR with the eyes closed.
Brilliant.
Great videos, they helped me a lot! Just out of curiosity, how do you film while doing the head impulse test, do you have a second person holding the phone or do you have some kind of phone mount? ;)
I have a relative or someone who is working with me hold the camera. Important that they know to turn the flash on, get close enough to include both eyebrows and several inches of forehead and nose in the video.
@@PeterJohns thanks for the quick reply, that‘s what I thought, I think the videos are a great tool for documentation and teleaching but it‘s not always easy to do if there‘s no one around to help
@@LukasDearing I did try once having the patient hold the phone. I placed a piece of tape on phone in the middle for them to focus on, had the flash on and I ensured the phone was the right distance and framing, then reach over them to do the HIT. A big awkward, but worked!
hi doctor, just clarifying when you say constant dizziness, do you mean dizziness that isn't just positional dependent like in BPPV, or do you mean dizziness always, all day (as these seems very unlikely for a patient to have).. Thank you!
Yes, the patient population who benefits from the HINTS exam are having either vestibular neuritis or posterior circulation stroke presenting with dizziness. Both those patient populations endorse having many hours or days of constant dizziness, which is worsened with head movements, but not brought on by head movements as BPPV is. In my emergency medicine practice, this kind of constant dizziness lasting all day was not unusual, and most had vestibular neuritis.
@@PeterJohns thank you for the clarification doctor
Sr. Could you talk about traumatic BPPV in your next vídeo?
What do you want to know about it? Not unusual after a had injury, and often involves multiple canals or both ears. Treat the most symptomatic one first, then then treat what's left after that.