one hour of watching some of your videos later I feel more competent than ever when assessing vertigo patients in the ER. Thank you very much! Going to watch all of the remaining videos later.
Thanks for the great review! When I was in training 2 decades ago, we were not taught the HINTS Plus. But in the US currently, the re-certification exams include it. So this is wonderful.
I like how you classify the result as Hints Plus peripheral or central. After studying your other videos this makes a lot of sense to me. Thank you for another great video!
Thanks for your comments and compliment. To call Hints or HINTS plus either central or peripheral was suggested in an article by Thomas and David Newman-Toker "Avoiding “HINTS Positive/Negative” to Minimize Diagnostic Confusion in Acute Vertigo and Dizziness" in The Journal of Acute Care Physical Therapy 2016. When someone says "I did the HINTS and it was negative" I really don't know what they mean.
More than once I have dragged my laptop into a treatment room to perform the Gafoni maneuver on a patient with ageotropic nystagmus. Thank you for sharing your expertise so that we, in distant locations...even South Dakota(!)..., can confidently diagnose and treat our dizzy patients.
Haha! thanks for the actual LOL! Glad to hear you are doing the right thing for your patients! But save your laptop, just take notes and remember your G's and A's!
@@PeterJohns Forgot to mention that the same patients, thanks to you to turn my generalist medic's eyes into a more helpful medic (after treating BPPV in emergency because all of your youtube's lessons and trying to not let pass a central vertigo as I did in 2 cases, referring correctly. Be sure, all your time doing this, worth it.). God bless you.
Thank you very much for your very useful videos. Seeing the different nystagmus with such great resolution is really helpful. There is one thing I would like you to comment on: the diagnosis of labyrinthitis. I have learned that it's clinical presentation is very similar to a vestibular neuritis, except for hearing loss. With HINTS, you would classify hearing loss as central origin. What would be your take on that? Have a great day!
Good question: I am curious about this, as well. Go ahead and image to screen for stroke even if labyrinthitis is suspected? I am a physical therapist with direct access, so need to know when to send to ED.
Slappin' info, my beautiful medical guy! Keep up the good work here on youtube. Most vertigo videos are pretty superficial and you can't really apply the skills at all afterwards because the information is too vague/inconsistent. Ex: central vertigo ALWAYS has a slow onset, peripheral ALWAYS has a sudden onset. How about stroke? So many times strokes are overlooked, people don't even look for them.
love your videos! Would there ever be a reason to see nystagmus (spontaneous or gaze evoked) in only 1 eye? (given the other eye has normal oculomotor function)?
Need to make a chart for BPPV three types and relative proportion of cases exam findings and treatment maneuvers and pearls of each such as posterior bloc with sitting up from bed and horizontal just turning head …. Also include anterior
My focus is to teach the non-vertigo dedicated clinician about things they will see in their practice occasionally. Anterior canal BPPV if quite rare, as is inferior VN, so I don't bring them up unless asked about them. I did mention in my HC BPPV video about turning the head cause vertigo.
Thanks this is a really nice approach. Do you have any advice for identifying which side the lesion is on based on the nystagmus saccade? I have read contradicting statements from different sources...
There is only one answer which is correct. But, it can be a bit confusing. In vestibular neuritis, the fast phase of the spontaneous, or gaze evoked nystagmus is away from the affected ear. When the head is turned rapidly towards the affected ear, there will be an abnormal catch up saccade. This saccade is in the same direction as the spontaneous nystagmus, but of larger amplitude. Watch this video at this time stamp for examples. ua-cam.com/video/XpghlvnrREI/v-deo.html
@@PeterJohns thank you so much for the fast and clear response. I hadn't expected you to still be responding to questions so long after this video was posted! Much appreciated before my clinical board exam. Kind regards from Sweden, Inge.
Actually the AICA (anterior inferior superior artery) supplies blood supply to the whole labyrinth. So that means an AICA stroke can affect parts of the cerebellum and pons as well as the cochlea (sensory end organ for hearing) the utricle and saccule and semicircular canals (sensory end organs for balance). So you have what appears to be an acute vestibular loss with an abnormal HIT, as well as a hearing loss.
Sir I have question when I did Dix pt was having nystagmus on sitting only from lying posture , so diagnosed as nonampullary post canal bppv . So your opinion and treatment
If the patient screens negative for the central features in the flow chart, and has no spontaneous (or gaze evoked) nystagmus, which means HINTS exam is not indicated, can you safely rule out cerebellar stroke then? Can cerebellar stroke present without any vertigo or spontaneous nystagmus at all - for example only ataxia and nausea/vomiting?
A few possibilities. 1. Look carefully for nystagmus. Remove fixation as by putting a blank piece of paper beside their head and asking them to look through it. If you do see some pathological nystagmus, then you can do HINTS plus. Sometimes in recovering vestibular neuritis (a few days old) the nystagmus is only seen this way. 2. If they are still dizzy when you see them, have no nystagmus even when fixation is removed, but have an acute disturbance in their gait (new difficulty walking) then this is what Machner has described as the Acute Imbalance Syndrome. pubmed.ncbi.nlm.nih.gov/32462345/ And these patients have a high risk of stroke. Delayed MRI is best. 3. If they have no nystagmus even when fixation is removed, and still say they are dizzy, which is is much worse with rolling over, getting in and out of bed, it's ok to test them for BPPV. Some BPPV patients do not say their dizziness goes away completely when they stay still. They will say "I'm still a bit dizzy". If diagnostic nystagmus for BPPV develops in the Dix-Hallpike test or supine roll test, you have your diagnosis. 4. Ask about previous dizzy episodes and history of headaches/migraines. Vestibular migraine often presents with dizziness but no nystagmus, or acute imbalance. See this video. ua-cam.com/video/XPIyXiv0UKg/v-deo.html Hope this helps!
One that has an interest in vertigo. Could be ENT or neurologist or family MD. But if they don't perform the Epley maneuver themselves, then they are not interested in vertigo.
Dr...about a month ago I got an episode of vertigo only had one possible 15 or so second one but since I've had short little feelings if dizziness and went to the dr twice she said nope not a stoke ..I have an spot with an ENT dec 3and im just living with this I'm scared that I may have another big episode I'm on meclizine doesnt seem to help as much as my lorazepam ..I don't have nostagmus when I do the eye test myself while recording in my cell..just so worried and scared but other than small bouts if very short dizziness I'm fine ..I feel like as you were reading the left side of the chart its me! Its exactly what I have so I'm praying its nothing more serious the ringing in my ears is quite a lot as well but no hearing loss ..anyhow Dr thank you for this advice ..do you suggest I see the ENT or a neurologist? Thanks Doc!!
One of my favourite medical teaching videos ever
Thanks Professor, learnig from your channel is worth more than hours and hours spent on books.
BEST EVER NOW APPROACG FOR VERTIGO SO CLEAR AS BEFORE WAS CONSUDED LITTLE BIT. THANK YOU.
I am a family medicine registrar in NZ as well, and this is just just outstanding! thanks Peter.
i am an ER physician, and all that i can say is well done sir, this has abolished years of vertigo myths !!
Very precise and detailed! Thanks for the upload
Thanks a lot Prof this was a super helpful review for a medical student from NZ :) Love your work
one hour of watching some of your videos later I feel more competent than ever when assessing vertigo patients in the ER. Thank you very much! Going to watch all of the remaining videos later.
Thanks for your precise and concise videos. Very useful.
Yet another excellent teaching video. Congratulations! And, thanks!
Thanks for the great review! When I was in training 2 decades ago, we were not taught the HINTS Plus. But in the US currently, the re-certification exams include it. So this is wonderful.
This is a great video on an oft poorly understood topic! Great job!!
When I see “dizzy” on the triage note, I can’t help but think of theses videos. Great Job 🙏
Thank you for making this video
Thank you for your hard work, this is one of your best presentations. Love them and enjoy watching them.
Helped me a whole lot, thanks
Thank you for teaching us, Professor.
I am now better equipped to treat my patients 🙏
Great content doc!!!
Amazing!! I can't get enough.
Excellent.
Muchas gracias.
I like how you classify the result as Hints Plus peripheral or central. After studying your other videos this makes a lot of sense to me. Thank you for another great video!
Thanks for your comments and compliment. To call Hints or HINTS plus either central or peripheral was suggested in an article by Thomas and David Newman-Toker "Avoiding “HINTS Positive/Negative” to Minimize Diagnostic Confusion in Acute Vertigo and Dizziness" in The Journal of Acute Care Physical Therapy 2016. When someone says "I did the HINTS and it was negative" I really don't know what they mean.
Thank you for these presentations, they have really helped me in practice
Glad to hear it! Feel free to ask questions or make comments if you have them.
More than once I have dragged my laptop into a treatment room to perform the Gafoni maneuver on a patient with ageotropic nystagmus. Thank you for sharing your expertise so that we, in distant locations...even South Dakota(!)..., can confidently diagnose and treat our dizzy patients.
Haha! thanks for the actual LOL! Glad to hear you are doing the right thing for your patients! But save your laptop, just take notes and remember your G's and A's!
outstanding indeed!
Thank you very much indeed.
Very usefull,thanks alot
Thanks professor, always coming back for your videos. My patients are better evaluated because of your experience's sharing.
I consider that the greatest compliment, thank you very much!
@@PeterJohns Forgot to mention that the same patients, thanks to you to turn my generalist medic's eyes into a more helpful medic (after treating BPPV in emergency because all of your youtube's lessons and trying to not let pass a central vertigo as I did in 2 cases, referring correctly. Be sure, all your time doing this, worth it.). God bless you.
Its the one of the best video about vertigo that i seen
Thanks a lot
God bless you
I am a new fan!!! New subscriber here.
Welcome! Hope to provide new content soon, but there is plenty already to view
Thank you very much for your very useful videos. Seeing the different nystagmus with such great resolution is really helpful. There is one thing I would like you to comment on: the diagnosis of labyrinthitis. I have learned that it's clinical presentation is very similar to a vestibular neuritis, except for hearing loss. With HINTS, you would classify hearing loss as central origin. What would be your take on that? Have a great day!
Good question: I am curious about this, as well. Go ahead and image to screen for stroke even if labyrinthitis is suspected? I am a physical therapist with direct access, so need to know when to send to ED.
Slappin' info, my beautiful medical guy! Keep up the good work here on youtube. Most vertigo videos are pretty superficial and you can't really apply the skills at all afterwards because the information is too vague/inconsistent. Ex: central vertigo ALWAYS has a slow onset, peripheral ALWAYS has a sudden onset. How about stroke? So many times strokes are overlooked, people don't even look for them.
love your videos! Would there ever be a reason to see nystagmus (spontaneous or gaze evoked) in only 1 eye? (given the other eye has normal oculomotor function)?
No, I can't think of a reason why this would happen. But I'm not an expert in all causes of dizziness/nystagmus
Need to make a chart for BPPV three types and relative proportion of cases exam findings and treatment maneuvers and pearls of each such as posterior bloc with sitting up from bed and horizontal just turning head …. Also include anterior
My focus is to teach the non-vertigo dedicated clinician about things they will see in their practice occasionally. Anterior canal BPPV if quite rare, as is inferior VN, so I don't bring them up unless asked about them. I did mention in my HC BPPV video about turning the head cause vertigo.
Thanks this is a really nice approach. Do you have any advice for identifying which side the lesion is on based on the nystagmus saccade? I have read contradicting statements from different sources...
There is only one answer which is correct. But, it can be a bit confusing. In vestibular neuritis, the fast phase of the spontaneous, or gaze evoked nystagmus is away from the affected ear. When the head is turned rapidly towards the affected ear, there will be an abnormal catch up saccade. This saccade is in the same direction as the spontaneous nystagmus, but of larger amplitude. Watch this video at this time stamp for examples. ua-cam.com/video/XpghlvnrREI/v-deo.html
@@PeterJohns thank you so much for the fast and clear response. I hadn't expected you to still be responding to questions so long after this video was posted! Much appreciated before my clinical board exam. Kind regards from Sweden, Inge.
@@ingepearson4842 I get sent notifications whenever someone comments on any of my videos. And your question was a good one!
so you say the HI test is may be abnormal for an AICA stroke? I don't follow that. is it due to the direct arterial supply to the vestibular nerve?
Actually the AICA (anterior inferior superior artery) supplies blood supply to the whole labyrinth. So that means an AICA stroke can affect parts of the cerebellum and pons as well as the cochlea (sensory end organ for hearing) the utricle and saccule and semicircular canals (sensory end organs for balance). So you have what appears to be an acute vestibular loss with an abnormal HIT, as well as a hearing loss.
Sir I have question when I did Dix pt was having nystagmus on sitting only from lying posture , so diagnosed as nonampullary post canal bppv . So your opinion and treatment
What kind of nystagmus?
If the patient screens negative for the central features in the flow chart, and has no spontaneous (or gaze evoked) nystagmus, which means HINTS exam is not indicated, can you safely rule out cerebellar stroke then? Can cerebellar stroke present without any vertigo or spontaneous nystagmus at all - for example only ataxia and nausea/vomiting?
Yes, see my tweet. twitter.com/PeterJohns84/status/1269013508290678791
How do you evaluate patients who have continuous vertigo, but no spontaneous nystagmus?
A few possibilities.
1. Look carefully for nystagmus. Remove fixation as by putting a blank piece of paper beside their head and asking them to look through it. If you do see some pathological nystagmus, then you can do HINTS plus. Sometimes in recovering vestibular neuritis (a few days old) the nystagmus is only seen this way.
2. If they are still dizzy when you see them, have no nystagmus even when fixation is removed, but have an acute disturbance in their gait (new difficulty walking) then this is what Machner has described as the Acute Imbalance Syndrome. pubmed.ncbi.nlm.nih.gov/32462345/ And these patients have a high risk of stroke. Delayed MRI is best.
3. If they have no nystagmus even when fixation is removed, and still say they are dizzy, which is is much worse with rolling over, getting in and out of bed, it's ok to test them for BPPV. Some BPPV patients do not say their dizziness goes away completely when they stay still. They will say "I'm still a bit dizzy". If diagnostic nystagmus for BPPV develops in the Dix-Hallpike test or supine roll test, you have your diagnosis.
4. Ask about previous dizzy episodes and history of headaches/migraines. Vestibular migraine often presents with dizziness but no nystagmus, or acute imbalance. See this video. ua-cam.com/video/XPIyXiv0UKg/v-deo.html
Hope this helps!
What type of Dr should I see to be evaluated for BPPV??
One that has an interest in vertigo. Could be ENT or neurologist or family MD. But if they don't perform the Epley maneuver themselves, then they are not interested in vertigo.
Thank you!
Dr...about a month ago I got an episode of vertigo only had one possible 15 or so second one but since I've had short little feelings if dizziness and went to the dr twice she said nope not a stoke ..I have an spot with an ENT dec 3and im just living with this I'm scared that I may have another big episode I'm on meclizine doesnt seem to help as much as my lorazepam ..I don't have nostagmus when I do the eye test myself while recording in my cell..just so worried and scared but other than small bouts if very short dizziness I'm fine ..I feel like as you were reading the left side of the chart its me! Its exactly what I have so I'm praying its nothing more serious the ringing in my ears is quite a lot as well but no hearing loss ..anyhow Dr thank you for this advice ..do you suggest I see the ENT or a neurologist? Thanks Doc!!