Hi Sir. This is Dr Abhinav, ENT surgeon from India. I follow you religiously and love all your videos. Thank you so much for them and keep posting. I have learnt alot from you
Your videos and teaching approach are outstanding! The high quality levels of education that can be found on UA-cam is astounding. I remember when I first started learning about doing vestibular rehabilitation in the year 2000 the only way to see nystagmus repeatedly (outside of the clinical setting) was to go to Emory University and watch videos on VCR tapes. Now I get to watch your awesome videos while folding laundry! Thanks again.
Thanks Andy! I agree that youtube is an excellent educational tool for teaching vertigo. Otherwise teaching vertigo without videos is like teaching ischemic chest pain without ECGs!
I saw a similar patient yesterday and went searching all over for this info. I wish you had uploaded this just a day earlier. Great video, thanks for sharing
I've had vertigo since 2005 when I woke up with the room spinning and rocking. I was vomiting and retching, unable to stand and completely helpless. I had to phone my doctor. He found me naked and helpless on the floor. I thought I had had a stroke or something. Was hospitalised for a week. It has improved since but any illness makes it worse including what I think was covid (undiagnosed) which really knocked me back. I don't have money for private treatment and have seen a few different consultants and received contradictory diagnoses. It seems that my case is too complicated for them and they don't have the time or are not being paid enough for a medical card patient (Republic of Ireland). My eyes feel like they dart about but I'm told by most I don't have nystagmus. Vestibular exercises help. I was on a course of Ribavirin and Interferon when it started. I'm fairly new to UA-cam and will try out the different exercises. My sympathys to all with this condition. People who have never had it don't understand how awful it is. I've actually had people laugh at me, including a medical "professional", after describing it.
Great video, Peter! I noticed that you changed the original “stand unaided” to “walk unaided”. This probably increase our diagnostic sensitivity, doesn’t it?
Thanks for the video! I am a 5th year medical student interested in vertigo. Can you recommend me any books or other sources so I can read more about this topic?
Hmmm.... there are so many. This recent journal had many good articles on vertigo. CONTINUUM: Lifelong Learning in Neurology Issue: Volume 27(2), April 2021
love it. Interesting choice of metoclopramide for nausea. Wouldn't it be better to use something that helps with vertigo like stematil (prochlorpreazine)?
It used to be my go-to drug for nausea, dizziness, headache, but IV prochlorperazine is no longer available in Canada where I work. Metoclopramide seems to work pretty much as well.
Hi Dr. Peter ! Your videos and teaching is simply awesome . I teach ENT to undergraduates. Can I use any of your video clips for teaching. I will give you video credit for the same . Thanks !
@@PeterJohns I am so glad you replied sir . I couldn’t find your email address in the About description in your channel.. Please let me know your email address. Thank u so much !
@@manishaent6872 Where you see my head photo above, , click on the "Peter Johns" to the right of it. On the next screen, click on "About" on that page, under "details" click on "view email address". That will show you my email address.
What do you mean by “spontaneous nystagmus?” Do you mean nystagmus on eye movements in a cranial nerve test or obvious nystagmus at rest when not looking anywhere particularly. Love your videos- watch the epley one frequently with patients. Many thanks. Essentially vertical nystagmus bad right?
Spontaneous nystagmus means nystagmus seen in primary gaze, ie looking straight ahead. It doesn't mean nystagmus that is brought on by positional testing such as the Dix-Hallpike test. With regards to vertical nystagmus, it is commonly seen in a positive Dix-Hallpike test. See this video. ua-cam.com/video/V4C_BRNf1EI/v-deo.html
Hi Peter, I have been practicing this approach for about 1-2 years. While encountering patient's presenting with acute vestibular syndrome, the head impulse test is probably the most difficult bedside test. Oftentimes the patient's resting nystagmus is quite subtle, which makes observation of the "correction saccade" quite difficult. Thus, many patients with AVS undergoing the big 3 diagnostic algorithm have no central features, no new hearing loss, no skew deviation, no vertical or multidirectional nystagmus. But they have equivocal result of HIT. I usually observe them in the ED for a couple of hours. If their symptom subsides, then I may give them the diagnosis of VN. However I am a bit worried that I could have delay the diagnosis of stroke. How often do you see a patient presenting with posterior circulation stroke and the only neurological deficit is a normal HIT?
Jason, in my experience, if a patient has any spontaneous nystagmus due to vestibular neuritis, I can see the abnormal correction saccade fairly easily. I wonder about your HIT technique. I'd be happy to have zoom call to discuss it. In terms of your last question, I have never seen a patient where the HIT was the only clue that it was a posterior circulation stroke. There seems to be quite a variation in how common certain causes of vertigo present to different areas. For instance, Dan Goldman, neuro-ototologist at Johns-Hopkins (colleague of David Newman-Toker) says that they almost never see vestibular neuritis there. I've had people tell me that patients at their hospital with dizziness rarely have BPPV. It's hard to understand sometimes.
@@PeterJohns I think I need to record a couple of clips before I make a zoom call. Thank you for your kindness. BTW, I feel a bit reassured after hearing your answer about "HIT as the only clue".
I personally don't believe that patients without nystagmus have AVS. It's in the original definition. Some people define AVS as acute vertigo or imbalance, and do not require nystagmus for the definition. I think that patients with acute imbalance and no nystagmus have another syndrome as defined by Machner. Machner published a study about the Acute Imbalance Syndrome. "Risk of acute brain lesions in dizzy patients presenting to the emergency room: who needs imaging and who does not?" For patients admitted to the hospital for uncertain diagnosis, if they had persistent dizziness in the ED, had NO nystagmus, but had a new acute change in their gait or ability to stand, 33% of them had lesions on delayed MRI. If they had high risk factors for stroke, 50% had lesions. Since the differential diagnosis of AVS is basically vestibular neuritis vs dizzy stroke, and virtually all patients with VN have nystagmus if you look very carefully for it, removing fixation with a piece of paper and having them look 30 degree off to each side, then if you don't see nystagmus, they don't have VN. And what does that leave you? A lot of strokes. Now, what about those who says they are still dizzy, have no nystagmus and have no objective difficulty walking? Assuming they have no central features, they are probably at very low risk of stroke. This hasn't been studied as far as I know, but I believe it to be true. They could have BPPV. 10% of BPPV complain of a certain amount of constant dizziness. They could have vestibular migraine. It's very common, and in one paper, 10% of AVS was diagnosed as VM. They could have some general medical cause like anemia or hyponatremia or many other causes dizziness not of vestibular cause. I really should make a video about this. Thanks for the question!
@@PeterJohns thank you so much for your answer. This is very much in line with the New Grace Guidelines who advise to use the standing algorithm in Avs( or not:)) without nystagmus. Thank you so much! Another question i have if you have the Time to answer is if New headache with dizziness irrespective of Quality would be an Indication for Imaging to Rule out cerebellar hemorrhage since i encounter a lot of such Patients in the ed. Thank you very much !
@@maxlichtenberger7447 Although GRACE-3 discussed STANDING protocol, it didn't have it in their 15 recommendations. I have concerns that if you can walk unaided, but have a clear new problem with gait and no nystagmus that you would be considered a peripheral cause by the STANDING protocol. I think any patient without nystagmus with a new objective change in gait you should be concerned about stroke. In terms of headache, if that was the only thing I could find on screening for central features that was positive and HINTS exam was all peripheral, it would have to be a fairly significant new headache before I ordered a CT head. And I have found if you ask carefully about other dizzy episodes and a history of headaches that are consistent with migraine, vestibular migraine is a much more common cause of vertigo than cerebellar hemorrhage.
In Norway patient's with vestibular neuritis are sometimes treated with a high dose of steroid(prednisolon) to reduce inflammation as this has shown beneficial withing 72 hours of debut. Is this common practice else where?
Hi Sir. This is Dr Abhinav, ENT surgeon from India. I follow you religiously and love all your videos. Thank you so much for them and keep posting. I have learnt alot from you
Your videos and teaching approach are outstanding! The high quality levels of education that can be found on UA-cam is astounding. I remember when I first started learning about doing vestibular rehabilitation in the year 2000 the only way to see nystagmus repeatedly (outside of the clinical setting) was to go to Emory University and watch videos on VCR tapes. Now I get to watch your awesome videos while folding laundry! Thanks again.
Thanks Andy! I agree that youtube is an excellent educational tool for teaching vertigo. Otherwise teaching vertigo without videos is like teaching ischemic chest pain without ECGs!
I saw a similar patient yesterday and went searching all over for this info. I wish you had uploaded this just a day earlier. Great video, thanks for sharing
I agree with Andy, outstanding video and videos! Thank you
Learned a lot from you, can't thank you enough.
your videos is a blessing sir , thank you very much !💞💞
It's very helpful! Thank you so much!
Fantastic video as always Sir.
I've had vertigo since 2005 when I woke up with the room spinning and rocking. I was vomiting and retching, unable to stand and completely helpless. I had to phone my doctor. He found me naked and helpless on the floor. I thought I had had a stroke or something. Was hospitalised for a week. It has improved since but any illness makes it worse including what I think was covid (undiagnosed) which really knocked me back. I don't have money for private treatment and have seen a few different consultants and received contradictory diagnoses. It seems that my case is too complicated for them and they don't have the time or are not being paid enough for a medical card patient (Republic of Ireland). My eyes feel like they dart about but I'm told by most I don't have nystagmus. Vestibular exercises help. I was on a course of Ribavirin and Interferon when it started. I'm fairly new to UA-cam and will try out the different exercises. My sympathys to all with this condition. People who have never had it don't understand how awful it is. I've actually had people laugh at me, including a medical "professional", after describing it.
Thanks a lot!
Great video, Peter! I noticed that you changed the original “stand unaided” to “walk unaided”. This probably increase our diagnostic sensitivity, doesn’t it?
Yes exactly.
Thanks for the video! I am a 5th year medical student interested in vertigo. Can you recommend me any books or other sources so I can read more about this topic?
Hmmm.... there are so many. This recent journal had many good articles on vertigo. CONTINUUM: Lifelong Learning in Neurology
Issue: Volume 27(2), April 2021
love it. Interesting choice of metoclopramide for nausea. Wouldn't it be better to use something that helps with vertigo like stematil (prochlorpreazine)?
It used to be my go-to drug for nausea, dizziness, headache, but IV prochlorperazine is no longer available in Canada where I work. Metoclopramide seems to work pretty much as well.
Hi Dr. Peter ! Your videos and teaching is simply awesome . I teach ENT to undergraduates. Can I use any of your video clips for teaching. I will give you video credit for the same . Thanks !
Hi, send me an email about this. On my channel, click on "about" and then "view email address" and send me your request. Thanks!
@@PeterJohns I am so glad you replied sir . I couldn’t find your email address in the About description in your channel.. Please let me know your email address. Thank u so much !
@@manishaent6872 Where you see my head photo above, , click on the "Peter Johns" to the right of it. On the next screen, click on "About" on that page, under "details" click on "view email address". That will show you my email address.
What do you mean by “spontaneous nystagmus?” Do you mean nystagmus on eye movements in a cranial nerve test or obvious nystagmus at rest when not looking anywhere particularly. Love your videos- watch the epley one frequently with patients. Many thanks. Essentially vertical nystagmus bad right?
Spontaneous nystagmus means nystagmus seen in primary gaze, ie looking straight ahead. It doesn't mean nystagmus that is brought on by positional testing such as the Dix-Hallpike test. With regards to vertical nystagmus, it is commonly seen in a positive Dix-Hallpike test. See this video. ua-cam.com/video/V4C_BRNf1EI/v-deo.html
I have always known that a hearing loss actually indicates a peripheral problem like meniers disease !
Hi Peter, I have been practicing this approach for about 1-2 years. While encountering patient's presenting with acute vestibular syndrome, the head impulse test is probably the most difficult bedside test. Oftentimes the patient's resting nystagmus is quite subtle, which makes observation of the "correction saccade" quite difficult. Thus, many patients with AVS undergoing the big 3 diagnostic algorithm have no central features, no new hearing loss, no skew deviation, no vertical or multidirectional nystagmus. But they have equivocal result of HIT. I usually observe them in the ED for a couple of hours. If their symptom subsides, then I may give them the diagnosis of VN. However I am a bit worried that I could have delay the diagnosis of stroke.
How often do you see a patient presenting with posterior circulation stroke and the only neurological deficit is a normal HIT?
Jason, in my experience, if a patient has any spontaneous nystagmus due to vestibular neuritis, I can see the abnormal correction saccade fairly easily. I wonder about your HIT technique. I'd be happy to have zoom call to discuss it. In terms of your last question, I have never seen a patient where the HIT was the only clue that it was a posterior circulation stroke.
There seems to be quite a variation in how common certain causes of vertigo present to different areas. For instance, Dan Goldman, neuro-ototologist at Johns-Hopkins (colleague of David Newman-Toker) says that they almost never see vestibular neuritis there. I've had people tell me that patients at their hospital with dizziness rarely have BPPV. It's hard to understand sometimes.
@@PeterJohns I think I need to record a couple of clips before I make a zoom call. Thank you for your kindness. BTW, I feel a bit reassured after hearing your answer about "HIT as the only clue".
@@PeterJohns Thank you for letting me zoom you! I think I should try hard to record some clips.
What to do when there Are no Central Features and when there is no Nystagmus? But AvS
I personally don't believe that patients without nystagmus have AVS. It's in the original definition. Some people define AVS as acute vertigo or imbalance, and do not require nystagmus for the definition. I think that patients with acute imbalance and no nystagmus have another syndrome as defined by Machner.
Machner published a study about the Acute Imbalance Syndrome. "Risk of acute brain lesions in dizzy patients presenting to the emergency room: who needs imaging and who does not?" For patients admitted to the hospital for uncertain diagnosis, if they had persistent dizziness in the ED, had NO nystagmus, but had a new acute change in their gait or ability to stand, 33% of them had lesions on delayed MRI. If they had high risk factors for stroke, 50% had lesions.
Since the differential diagnosis of AVS is basically vestibular neuritis vs dizzy stroke, and virtually all patients with VN have nystagmus if you look very carefully for it, removing fixation with a piece of paper and having them look 30 degree off to each side, then if you don't see nystagmus, they don't have VN. And what does that leave you? A lot of strokes.
Now, what about those who says they are still dizzy, have no nystagmus and have no objective difficulty walking? Assuming they have no central features, they are probably at very low risk of stroke. This hasn't been studied as far as I know, but I believe it to be true.
They could have BPPV. 10% of BPPV complain of a certain amount of constant dizziness. They could have vestibular migraine. It's very common, and in one paper, 10% of AVS was diagnosed as VM.
They could have some general medical cause like anemia or hyponatremia or many other causes dizziness not of vestibular cause.
I really should make a video about this.
Thanks for the question!
@@PeterJohns thank you so much for your answer. This is very much in line with the New Grace Guidelines who advise to use the standing algorithm in Avs( or not:)) without nystagmus.
Thank you so much! Another question i have if you have the Time to answer is if New headache with dizziness irrespective of Quality would be an Indication for Imaging to Rule out cerebellar hemorrhage since i encounter a lot of such Patients in the ed.
Thank you very much !
@@maxlichtenberger7447 Although GRACE-3 discussed STANDING protocol, it didn't have it in their 15 recommendations. I have concerns that if you can walk unaided, but have a clear new problem with gait and no nystagmus that you would be considered a peripheral cause by the STANDING protocol. I think any patient without nystagmus with a new objective change in gait you should be concerned about stroke.
In terms of headache, if that was the only thing I could find on screening for central features that was positive and HINTS exam was all peripheral, it would have to be a fairly significant new headache before I ordered a CT head. And I have found if you ask carefully about other dizzy episodes and a history of headaches that are consistent with migraine, vestibular migraine is a much more common cause of vertigo than cerebellar hemorrhage.
In Norway patient's with vestibular neuritis are sometimes treated with a high dose of steroid(prednisolon) to reduce inflammation as this has shown beneficial withing 72 hours of debut. Is this common practice else where?
The Cochrane review concludes there isn't enough evidence to support it's use. I agree with this view. However, I know some do prescribe steroids.
Yes, we do the same in India too. Though as already mentioned by Dr. Jones, we don't have very strong evidence