Very kind of you to say that. But I can tell you that my expertise is trying to teach people the basics of the common vertigo presentations. The real vertigo experts are on a level of understanding way above mine.
I'm a surgical resident with some experience in the ER pre-residency. Honestly, I wish somebody taught us surgery this way. Thank you sir! Your videos are truly enlightening!
Dr. Johns, just want to say thank you so much for your wisdom and expertise. As a PT who aspires to learn more and more about vestibular treatment, this has been a godsend for both me AND my patients. We appreciate you!
Thank you for the videos. We are forming a vestibular commity and your explanations were clear and thorough. Also appreciate your patients helping us learn.
Thanks! A recent study by Messina (ACTA OTORHINOLARYNGOLOGICA ITALICA 2017;37:328-335; doi: 10.14639/0392-100X-1121) in Italian vestibular clinics found that of 2682 patients with BPPV, 38% had Horizontal Canal BPPV. I think it's way more common than commonly thought. Once I started doing the supine roll test, I was amazed at all the patients in the emergency department with symptoms of BPPV who had Horizontal canal BPPV.
@@PeterJohns It is my experience too, that you see maybe 40-50% of your BPPV patients in the ED, with horizontal canal BPPV and not uncommonly apogeotrophic. At least considerably more than what is quoted in the litterature (usually 10-15%)
Thank you Dr. Johns. I learned diagnosis and treatment of hc-BPPV from this video and treated some patients. I think Gufoni maneuver is very effective for hc-BPPV.
Great video, Peter! Thank you for the information! Do you have a video that talks about cupulolisthiasis vs. canalisthiasis? I'm working with a patient with apogeotropic horizontal nystagmus that's worse when lying on the left side, indicating his right side is involved. I did the Gufoni on the right a couple times with no result, then I tried the BBQ roll instead, again treating the right ear and starting on that side. During the BBQ roll, it appeared to me that his vertigo just wouldn't stop, and I was thinking this might be indicative of the crystals being stuck to the cupula. I did some gentle manual vibration/cupping of his head when he was rolled onto his left side, and this helped clear things up. I then completed the BBQ roll, ending on the right, and then his nystagmus seemed to be cleared when I did the Supine Roll Test again. Can you share any insights or advice? Thanks again! - Luke
Horizontal canal BPPV often exhibit "pseudospontaneous" and persistent nystagmus. I'm thinking of making a video deep diving into horizontal canal BPPV, as the clinical presentation, diagnosis and treatment is more tricky than good old posterior canal BPPV. Some propose a "light cupula "theory. I can send you a couple of references if you're interested.
Thank you for the reply. A video in the future would be great! And any information can you share would be much appreciated. My email is luke@gordonphysicaltherapy.com Thanks again!
So I have horizontal nystagmus but my ENT doctors don't suspect that I have BPPV. They think it's potentially a central issue. But my neurologist doesn't think it's central. Brain MRI, CT of ear, normal. Only thing not normal is my VNG test. I'm not sure what other test we can do or what we should be looking for to see if it's central or not. Have you had any patients who had a hard time figuring out the cause?
Thank you so much for this amazing video! i’m not a vertigo treating professional I’m actually a patient who gets multiple BPPV episodes a year, with the last one being HC- BPPV. I actually diagnosed it myself after so much search because I would get spinning anywhere I rolled, when I looked sideways and up or down! I did the BBQ roll and on the second day it was already much better. My question is, do you think it’s possible that a patient can diagnose themselves and determine which canal and which ear are invloved? Can Patients video record their nystagmus and identify it themselves if they can? Does a HOrizontal nystagmus actually feel like horizontal beating to the patient? Like visually I mean? I’m asking this because it’s not always easy or fast enough seeing a an ENT or a vestibular therapist when an episode of BPPV decides to show up and ruin my plans.
My brother and his adult daughter, both with no medical training, watched this video and diagnosed and cured his geotropic HC BPPV. They videoed his nystagmus during the supine roll test. I think the patient's feeling of the direction nystagmus is not a reliable way to diagnose what is going on. But video, yes.
Thanks a lot to you and your team and patients for the absolutely clear understanding video in the best possible way one can ever think of.God bless you sir. I wish I could learn such things from you in person which will be a life long memory. Best of luck for the future sir. Congrats.
Excellent questions. So horizontal canal BPPV can be a bit confusing. You can either say:" For both geotropic and apogeotropic HC BPPV, on the side where the nystagmus is more intense, the direction of the fast phase of the nystagmus is pointing towards the affected ear" Or you can say "For geotropic HC BPPV, on the side where the nystagmus is more intense, the downward ear is the affected ear. For apogeotropic HC BPPV, on the side where the nystagmus is more intense, the upward ear is the affected ear." Either way, it can confuse people, which is why I always show real life examples. Thank for the question!
I do show it in this video at this time stamp ua-cam.com/video/iOJOArGmepM/v-deo.html I personally prefer the Gufoni, as it is easier in large or frail individuals, takes less time and works very well.
Thank you so much! Can vertigo with horizontal nystagmus occur if the patient is simply supine (head straight) in a person with a horizontal canal BPPV? I mean it occurs not only when head is turned to the right/left.
After a day of pondering, I have a clearer understanding now. Combined with the examples in your video, the premise for diagnosing the location of the horizontal BPPV should be that the otoliths often stay at the far end (tip) of the canal, and rarely right by the ampulla. Is that correct?
It is true that in the more frequent geotropic HC BPPV it is thought the otoliths are in the posterior arm of the horizontal canal. And in the somewhat less common apogeotropic HC BPPV, the otoliths are in the anterior arm of the horizontal canal. I discuss that in an earlier video on HC BPPV. ua-cam.com/video/iOJOArGmepM/v-deo.html
Dr, im still confused about the 2nd patient video. He had a more intense apogeotropic nystagmus when his head turn on the right, but you diagnosed him as having left apogeo horizontal BPPV. Are you referring that we identify the affected ear by the direction of the fast phase nystagmus?
Here is an answer I posted a year ago. I think it clears it up. "Generally, in HC BPPV, when you do the supine roll test, one side will show nystagmus which is faster/more amplitude than the other side. To figure out the affected side, you can think it in two ways. In this video, I say that the more intense nystagmus is pointing towards the affected side. That is, the fast direction of the nystagmus is in the direction of the affected side. And that is true for both geotropic and apogeotropic. The other way to say the same thing is: On the side that shows the more intense nystagmus, in geotropic, the affected ear is the downward ear. In apogeotropic, the affected ear is the upward ear."
Thank youvery much Dr. Johns for the incredibly informative video. I have also watched your older video concerning horizontal canal BPPV and I would like to ask you a question: in your other video ,you state that in the apogeotropic horizontal canal BPPV, the affected side is the one where the nystagmus is less intense. Could please enlighten me on which is correct? Thank you so much!
Generally, in HC BPPV, when you do the supine roll test, one side will show nystagmus which is faster/more amplitude than the other side. To figure out the affected side, you can think it in two ways. In this video, I say that the more intense nystagmus is pointing towards the affected side. That is, the fast direction of the nystagmus is in the direction of the affected side. And that is true for both geotropic and apogeotropic. The other way to say the same thing is: On the side that shows the more intense nystagmus, in geotropic, the affected ear is the downward ear. In apogeotropic, the affected ear is the upward ear. Hope this helps!
@@PeterJohns This makes everything clear. Thank you for your response. I actually had a patient with left ear apogeotropic horizontal canal BPPV( more intense apogeotropic nystagmus with the right ear downwards,thus nystagmus pointing to the left ear) and could manage it correctly thanks to you. She could be discharged without vertigo. Thank you!
67 yo female; dizzy only in body right (geo tropic nystagmus) and body left (square wave jerks) via Neurolign Dx100 VOG today. She was not dizzy. Saw her Sunday at her home for initial bout. She was able to move rapidly supine-seared-standing w/ o issue. Dix L & R WNL in both light & dark. Body left & right caused dizziness w/o nystagmus in light; with Vestibular 1st goggles I saw left ear apogeotropic hc bppv. Did left gufoni for left apogeotropic and she’s not dizzy. But today’s right beat geo tropic has me scratching my head. Her BP fluctuates up to 180 systolic w meds. Is this crystals or a degenerating brain? Love to share the videos for when it’s not that clear.
I can't answer that question. But I would say that when patients with apogeotropic HC BPPV are treated with the appropriate Gufoni maneuver for apogeotropic, they often convert to geotropic. And then if appropriate Gufoni maneuver for geotropic is applied, this often cured them.
As a side note , can you self diagnose the difference between horizontal and vertical torsional nystagmus? Is the perceived rotation different? Can one sense the absence of a torsional component?
There is no maneuver that works 100% the first time. If supine roll test after the maneuver still shows the same nystagmus, the same maneuver should be repeated.
Thank you so much for all the great ED vertigo content on your youtube channel! For this particular video I have one question: In an article you reference in your BPPV videos (Neil Bhattacharyya et al 2017, Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update)), in figure 7 and table 15 it shows that for the horizontal canal BPPV with apogeotrophic nystagmus, you should do a gufoni's with either the head up or the head down. I'm not sure whether to do both of these versions or just to do one of them depending on my suspicion of canalithiasis or cupolithiasis. It seems that, since they are showing the "face-down" version in the paper, that would be the primary one to do? Thanks! All the best from a scandinavian EM resident
In your first video of the woman with the geotropic HC BPPV, it seems that when her head is turned to the left, the fast component of the nystagmus appears to be to the left, but when her head is turned to the right the fast component is to the right and more exaggerated. Would this not be a bidirectional nystagmus?
An excellent question! Short answer is no. Long answer is: Bidirectional nystagmus refers to nystagmus where the direction of the nystagmus changes direction depending on the direction of the gaze of the patient. That is, if the patient gazes to the left, the nystagmus is to the left, if the patient gazes to the right, the nystagmus is to the right. There is no peripheral disorder that causes this, so the patient must have a central disorder. In both patients in the video above, the direction of the nystagmus changes during a provocative positional test, the supine roll test. It is not direction changing with gaze. It IS direction changing depending on which way the head is turned, but that is an expected finding in horizontal canal BPPV. Similar to the fact that spontaneous vertical nystagmus is a central finding, but vertical nystagmus (with a rotatory component towards the downward ear) is an expected finding in the Dix-Hallpike test and diagnostic of posterior canal BPPV. Thanks for the question!
Hi, thanks again for all your videos that are very helful! I learn in my vestibular class that the head should be flex 30° in the supine roll test but you don't seem to do that, what are your thoughts about that! Thanks!
I think anatomically it makes sense, since the horizontal canal is 30 degrees slanted down from anterior to posterior, but practically, since they are supine, probably doesn't make much difference. Hence, I try and make things as simple as possible for my learners. Supine roll test- lie them supine.
What about a vestibular weakness? Positional nystagmus may also be related to weakness. So wouldn't it be appropriate to perform VNG with Dix-Halpike + bi-thermal and bi-caloric assessment?
The most common cause of vertigo see in almost any clinical scenario is BPPV. Horizontal canal BPPV can be as high as 30 or 40% of cases of BPPV. If the nystagmus seen is typical of horizontal canal BPPV, and the patient is cured by a particle repositioning maneuver such as the Gufoni maneuver, then there is no indication for VNG or other vestibular tests.
Thank you doctor Johns, I have been diagnosed BPPV over a year and a half ago. I had several test done at Toronto East General with water in my year but they did not do a test (Dix Hallpike test) to determine which type of BPPV I had. A Physiotherapist I saw on 3 sessions applied his own manoeuvre which did a very violent shaking of my head with rolling me to the sides several times. I got someone better but I felt that I still had vertigo; in bed if I turn my head towards my right ear I felt a mild vertigo/dizziness. Occasionally I would do the Eppley manoeuvre on my own and would feel better however with the sense that I was not feeling perfectly well. This past week the vertigo returned again very intensely. When I do the Eppley manoeuvre starting on the right side I get pronounce nystagmus that eventually stops, turn to the left side and get mild nystagmus and when I do the turn looking down the nystagmus is severe and I cannot hold it and have to stop. I suspect that I might not have PC BPPV and maybe I have HC BPPV. Is there anyone in Toronto that would be able to perform the tests on me and apply the correct manoeuvre?
Thanks Professor. So it’s at last regardless of apogeotropic or geotropic- it’s Good ear towards ground turned 45degree and make the patient sit. Am I correct ?
The nystagmus of horizontal canal BPPV is horizontal. The direction of the nystagmus is from the perspective of the patient's head. So it is beating towards one ear or the other.
I got quite confused when performing the test on a real patient yesterday. would it be easier to understand it this way? For GEOtropic nystagmus, the more intense side is the affected side For APOgeotropic nystagmus, the more intense side is NOT the affected side
A year ago someone asked a similar question, and I responded as below: Generally, in HC BPPV, when you do the supine roll test, one side will show nystagmus which is faster/more amplitude than the other side. To figure out the affected side, you can think it in two ways. In this video, I say that the more intense nystagmus is pointing towards the affected side. That is, the fast direction of the nystagmus is in the direction of the affected side. And that is true for both geotropic and apogeotropic. The other way to say the same thing is: On the side that shows the more intense nystagmus, in geotropic, the affected ear is the downward ear. In apogeotropic, the affected ear is the upward ear. Hope this helps!
@@PeterJohns i like the 2nd interpretation ! for me that is easier to understand. thanks , i learnt so much from this channel and my patients have benefitted alot as well
Sir, You Deserve a Noble Price for Giving such Life Saving (Almost) Exercises...I have horizontal Nystagmus before taking Medicines and my Spinning has Reduce upto 60%. But the Floating Feeling is not going from inside me... Doctor has advice me to just to make Semont Maneuver to reduce it.. Can you please suggest me something which can help my Floating Feeling or It can be Imbalancing..
If, when you are lying down and the turning your head to so that your ear touches the bed,, you have horizontal nystagmus, then the Semont maneuver will not help you as it is for posterior canal BPPV. The video I made is for horizontal canal BPPV.
I tried Epley twice and realized it may be incorrect as condition persists. Determined it may need Gufoni instead. Tried it out last evening. Hope vertigo will subside. One question: how long does vertigo persists after Gufoni? Any advice, anyone?
To diagnose horizontal canal BPPV, the typical nystagmus must be observed. So I don't really know what you have, and I'd rather not comment further. Hope you feel better soon.
Thank you so much for your wonderful videos. Your video on Dix-hallpike and Epley's cleared so much of my confusions. However, I do still have questions concerning this horizontal canal test. As I understand it, the intensity as well as the direction (apogeotropic or geotropic) of the nystagmus should rely on the location of the otolith in the canal. If it's located at the opposite side of the ampulla, it should create geotropic movement; and apogeotropic movement if it's located at the same side to the ampulla (coz it moves to the opposite direction of the ampulla when the head turns to the side of the troubled ear and creates inhibitory signals, right?)... However, the intensity of the nystagmus should be decided by the distance of the otolith from the base (vestibule), since the farthest position (such as at the tip of the canal) would create the biggest momentum and thus strongest stimulation to the receptors... Therefore I'm a bit confused when you said that the stronger side decides the laterality of the BPPV, since the way I understand it, the distance of the otolith is irrelavant to laterality. Is there something wrong in my understanding? Plus, how often do otoliths locate right at the tip of the canal, or right at the ampulla?
This is helping me a lot! but I don't understand why the affected ear of the second patient is the left one, If the Ny was more intense when he turns his head to the right. Isn't it an Apogeotropic Ny which it could means that is a cupulolithiasis?
You can either say:" For both geotropic and apogeotropic HC BPPV, on the side where the nystagmus is more intense, the direction of the fast phase of the nystagmus is pointing towards the affected ear" Or you can say "For geotropic HC BPPV, on the side where the nystagmus is more intense, the downward ear is the affected ear. For apogeotropic HC BPPV, on the side where the nystagmus is more intense, the upward ear is the affected ear." I saw that you already answer that. Thanks!! Hope you upload more videos, Thanks for teaching us with real life examples! this is a bit difficult to think for me! greetings from Buenos Aires, Argentina
The best cure are these maneuvers. If people are having trouble tolerating the maneuvers, an anti-emetic can be given before. Vit D may play a role in prevention of BPPV.
Hi, I’m one of the followers of your excellent videos on BPPV. I’m somewhat confused about the determining the affected side in ageotropic horizontal canal BPPV in supine roll test. In your first video (ua-cam.com/video/iOJOArGmepM/v-deo.html) on the horizontal canal BPPV you mentioned the affected side, the side with less intense nystagmus while in this video the side with more intense nystagmus like the geotropic type. Which one is correct?
I say the same thing but in different ways I think. Two ways to think of it. Yes, in HC BPPV, one side usually has a stronger nystagmus and symptoms than the other side. So one way to think of it is: with the head turned towards the stronger nystagmus and patient symptoms, in geotropic, the affected ear is the downward ear. In apogeotropic, the affected ear is the upper ear. The way I explained it here was: in both geotropic and apogeotropic, the nystagmus is "pointing" towards the affected ear. So in geo, it points down, and in apogeo, it points upward. Hope this helps.
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The most authentic, well researched and easily explained vertigo resources. You are the biggest vertigo authority on globe sir....
Very kind of you to say that. But I can tell you that my expertise is trying to teach people the basics of the common vertigo presentations. The real vertigo experts are on a level of understanding way above mine.
I'm a surgical resident with some experience in the ER pre-residency. Honestly, I wish somebody taught us surgery this way. Thank you sir! Your videos are truly enlightening!
Funny jeet
Your Videos concerning the different forms of BPPV are superb teaching!!! Thanks a lot for that!
Im a physio, this video helped me immensely when confused with a patient. Thanks for the post.
Glad it helped!
I second that!!! Very helpful when Epley failed!!!
Dr. Johns, just want to say thank you so much for your wisdom and expertise. As a PT who aspires to learn more and more about vestibular treatment, this has been a godsend for both me AND my patients. We appreciate you!
Iam a practising ENT Surgeon from India.I found this video extremely concise and informative.Thankyou.
Thank you for the videos. We are forming a vestibular commity and your explanations were clear and thorough. Also appreciate your patients helping us learn.
BY FAR THE BEST VIDEO about horizontal canal bppv. Amazing. Thank you Sir.
This is a great video! It's a great reminder that Epley's don't fix everything, and there are other canals besides the posterior canal.
Thanks!
A recent study by Messina (ACTA OTORHINOLARYNGOLOGICA ITALICA 2017;37:328-335; doi: 10.14639/0392-100X-1121) in Italian vestibular clinics found that of 2682 patients with BPPV, 38% had Horizontal Canal BPPV. I think it's way more common than commonly thought. Once I started doing the supine roll test, I was amazed at all the patients in the emergency department with symptoms of BPPV who had Horizontal canal BPPV.
@@PeterJohns It is my experience too, that you see maybe 40-50% of your BPPV patients in the ED, with horizontal canal BPPV and not uncommonly apogeotrophic. At least considerably more than what is quoted in the litterature (usually 10-15%)
@@Tagmose89 Great feedback. Once you know how to diagnose it, it starts showing up all the time!
Thank you Dr. Johns. I learned diagnosis and treatment of hc-BPPV from this video and treated some patients. I think Gufoni maneuver is very effective for hc-BPPV.
Last month I successfully cured a patient with right geoteopic lateral canal bppv, this is because of your videos.
Thanks!
This is a Gem. A keeper forever. Thanks for the clear understanding and life changing demos!
Can you do the video where laterally you have continuous nystagmus due to cupulothiasis, debris is stuck vs free floating, canathiasis.
Finally someone who explains it clearly
Great video, Peter! Thank you for the information! Do you have a video that talks about cupulolisthiasis vs. canalisthiasis? I'm working with a patient with apogeotropic horizontal nystagmus that's worse when lying on the left side, indicating his right side is involved. I did the Gufoni on the right a couple times with no result, then I tried the BBQ roll instead, again treating the right ear and starting on that side. During the BBQ roll, it appeared to me that his vertigo just wouldn't stop, and I was thinking this might be indicative of the crystals being stuck to the cupula. I did some gentle manual vibration/cupping of his head when he was rolled onto his left side, and this helped clear things up. I then completed the BBQ roll, ending on the right, and then his nystagmus seemed to be cleared when I did the Supine Roll Test again. Can you share any insights or advice? Thanks again! - Luke
Horizontal canal BPPV often exhibit "pseudospontaneous" and persistent nystagmus. I'm thinking of making a video deep diving into horizontal canal BPPV, as the clinical presentation, diagnosis and treatment is more tricky than good old posterior canal BPPV. Some propose a "light cupula "theory. I can send you a couple of references if you're interested.
Thank you for the reply. A video in the future would be great! And any information can you share would be much appreciated. My email is luke@gordonphysicaltherapy.com Thanks again!
@@PeterJohnsI would be interested too if that's possible. I'm treating a patient just as described above
So I have horizontal nystagmus but my ENT doctors don't suspect that I have BPPV. They think it's potentially a central issue. But my neurologist doesn't think it's central. Brain MRI, CT of ear, normal. Only thing not normal is my VNG test. I'm not sure what other test we can do or what we should be looking for to see if it's central or not. Have you had any patients who had a hard time figuring out the cause?
Thank you so much for this amazing video! i’m not a vertigo treating professional I’m actually a patient who gets multiple BPPV episodes a year, with the last one being HC- BPPV. I actually diagnosed it myself after so much search because I would get spinning anywhere I rolled, when I looked sideways and up or down! I did the BBQ roll and on the second day it was already much better. My question is, do you think it’s possible that a patient can diagnose themselves and determine which canal and which ear are invloved? Can Patients video record their nystagmus and identify it themselves if they can? Does a HOrizontal nystagmus actually feel like horizontal beating to the patient? Like visually I mean? I’m asking this because it’s not always easy or fast enough seeing a an ENT or a vestibular therapist when an episode of BPPV decides to show up and ruin my plans.
My brother and his adult daughter, both with no medical training, watched this video and diagnosed and cured his geotropic HC BPPV. They videoed his nystagmus during the supine roll test. I think the patient's feeling of the direction nystagmus is not a reliable way to diagnose what is going on. But video, yes.
@@PeterJohns that would be so empowering! Thank you for replying and I will keep watching your videos for more information.
Thanks a lot to you and your team and patients for the absolutely clear understanding video in the best possible way one can ever think of.God bless you sir. I wish I could learn such things from you in person which will be a life long memory. Best of luck for the future sir. Congrats.
Isn't the affected ear in those apogeotropic nystagmus to the side with LESS prominent nystagmus?
Excellent questions.
So horizontal canal BPPV can be a bit confusing.
You can either say:" For both geotropic and apogeotropic HC BPPV, on the side where the nystagmus is more intense, the direction of the fast phase of the nystagmus is pointing towards the affected ear"
Or you can say "For geotropic HC BPPV, on the side where the nystagmus is more intense, the downward ear is the affected ear. For apogeotropic HC BPPV, on the side where the nystagmus is more intense, the upward ear is the affected ear."
Either way, it can confuse people, which is why I always show real life examples.
Thank for the question!
Is it possible to have both bppv?
Thanks a lot
Hi Peter. Your videos are great! Can you please provide a video of the BBQ ROLL technique?
I do show it in this video at this time stamp ua-cam.com/video/iOJOArGmepM/v-deo.html I personally prefer the Gufoni, as it is easier in large or frail individuals, takes less time and works very well.
What is the difference between gufoni and lempert maneuver? When is lempert done compared to gufoni?
They both treat HC BPPV. I personally prefer Fufoni, as it is easier to do with frail or large patients than the Lempert (BBQ roll) maneuver.
Thank you so much! Can vertigo with horizontal nystagmus occur if the patient is simply supine (head straight) in a person with a horizontal canal BPPV? I mean it occurs not only when head is turned to the right/left.
@@sergeyryabov7262 Yes, this is often seen. In apogeotropic, the nystagmus in lying straight back usually beats towards the affected ear.
After a day of pondering, I have a clearer understanding now. Combined with the examples in your video, the premise for diagnosing the location of the horizontal BPPV should be that the otoliths often stay at the far end (tip) of the canal, and rarely right by the ampulla. Is that correct?
It is true that in the more frequent geotropic HC BPPV it is thought the otoliths are in the posterior arm of the horizontal canal. And in the somewhat less common apogeotropic HC BPPV, the otoliths are in the anterior arm of the horizontal canal. I discuss that in an earlier video on HC BPPV. ua-cam.com/video/iOJOArGmepM/v-deo.html
Dr, im still confused about the 2nd patient video. He had a more intense apogeotropic nystagmus when his head turn on the right, but you diagnosed him as having left apogeo horizontal BPPV. Are you referring that we identify the affected ear by the direction of the fast phase nystagmus?
Here is an answer I posted a year ago. I think it clears it up.
"Generally, in HC BPPV, when you do the supine roll test, one side will show nystagmus which is faster/more amplitude than the other side. To figure out the affected side, you can think it in two ways. In this video, I say that the more intense nystagmus is pointing towards the affected side. That is, the fast direction of the nystagmus is in the direction of the affected side. And that is true for both geotropic and apogeotropic.
The other way to say the same thing is: On the side that shows the more intense nystagmus, in geotropic, the affected ear is the downward ear. In apogeotropic, the affected ear is the upward ear."
Very Very Very Helpful, Thank you for sharing this video with this nice acronym
Thank youvery much Dr. Johns for the incredibly informative video. I have also watched your older video concerning horizontal canal BPPV and I would like to ask you a question: in your other video ,you state that in the apogeotropic horizontal canal BPPV, the affected side is the one where the nystagmus is less intense. Could please enlighten me on which is correct?
Thank you so much!
Generally, in HC BPPV, when you do the supine roll test, one side will show nystagmus which is faster/more amplitude than the other side. To figure out the affected side, you can think it in two ways. In this video, I say that the more intense nystagmus is pointing towards the affected side. That is, the fast direction of the nystagmus is in the direction of the affected side. And that is true for both geotropic and apogeotropic.
The other way to say the same thing is: On the side that shows the more intense nystagmus, in geotropic, the affected ear is the downward ear. In apogeotropic, the affected ear is the upward ear. Hope this helps!
@@PeterJohns This makes everything clear. Thank you for your response. I actually had a patient with left ear apogeotropic horizontal canal BPPV( more intense apogeotropic nystagmus with the right ear downwards,thus nystagmus pointing to the left ear) and could manage it correctly thanks to you.
She could be discharged without vertigo. Thank you!
@@ΑνατοληΑναστασιαδη Great to hear! What's your background?
@@PeterJohns I am a neurology resident ,currently working in Germany
@@ΑνατοληΑναστασιαδη Great that you have learned this. Ensure your colleagues learn it too!
Terrific explanations. Where were you when I suffered mediocre lectures from untalented teachers ?
Depends. When did you train? I certainly did not learn anything useful about vertigo during my training. And I mean zero.
67 yo female; dizzy only in body right (geo tropic nystagmus) and body left (square wave jerks) via Neurolign Dx100 VOG today. She was not dizzy. Saw her Sunday at her home for initial bout. She was able to move rapidly supine-seared-standing w/ o issue. Dix L & R WNL in both light & dark. Body left & right caused dizziness w/o nystagmus in light; with Vestibular 1st goggles I saw left ear apogeotropic hc bppv. Did left gufoni for left apogeotropic and she’s not dizzy. But today’s right beat geo tropic has me scratching my head. Her BP fluctuates up to 180 systolic w meds. Is this crystals or a degenerating brain? Love to share the videos for when it’s not that clear.
I can't answer that question. But I would say that when patients with apogeotropic HC BPPV are treated with the appropriate Gufoni maneuver for apogeotropic, they often convert to geotropic. And then if appropriate Gufoni maneuver for geotropic is applied, this often cured them.
As a side note , can you self diagnose the difference between horizontal and vertical torsional nystagmus? Is the perceived rotation different? Can one sense the absence of a torsional component?
I think a vertigo dedicated clinician could. But most patients just feel that everything is moving and they are nauseated and having trouble walking.
Does this manoeuvre need to be repeated or should it work first time? Thanks 😊
There is no maneuver that works 100% the first time. If supine roll test after the maneuver still shows the same nystagmus, the same maneuver should be repeated.
Thank you so much for all the great ED vertigo content on your youtube channel!
For this particular video I have one question: In an article you reference in your BPPV videos (Neil Bhattacharyya et al 2017, Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update)), in figure 7 and table 15 it shows that for the horizontal canal BPPV with apogeotrophic nystagmus, you should do a gufoni's with either the head up or the head down. I'm not sure whether to do both of these versions or just to do one of them depending on my suspicion of canalithiasis or cupolithiasis. It seems that, since they are showing the "face-down" version in the paper, that would be the primary one to do?
Thanks! All the best from a scandinavian EM resident
I always do the head up for apogeotropic HC BPPV. Most of the time, I have to do a geotropic maneuver after that. I find it works very well.
@@PeterJohns Thank you so much!
thank you docs :) Helped to understand LSCC BPPV from korea
Thank you so much! Your explanation is genius!
In your first video of the woman with the geotropic HC BPPV, it seems that when her head is turned to the left, the fast component of the nystagmus appears to be to the left, but when her head is turned to the right the fast component is to the right and more exaggerated. Would this not be a bidirectional nystagmus?
An excellent question! Short answer is no. Long answer is: Bidirectional nystagmus refers to nystagmus where the direction of the nystagmus changes direction depending on the direction of the gaze of the patient. That is, if the patient gazes to the left, the nystagmus is to the left, if the patient gazes to the right, the nystagmus is to the right. There is no peripheral disorder that causes this, so the patient must have a central disorder.
In both patients in the video above, the direction of the nystagmus changes during a provocative positional test, the supine roll test. It is not direction changing with gaze. It IS direction changing depending on which way the head is turned, but that is an expected finding in horizontal canal BPPV.
Similar to the fact that spontaneous vertical nystagmus is a central finding, but vertical nystagmus (with a rotatory component towards the downward ear) is an expected finding in the Dix-Hallpike test and diagnostic of posterior canal BPPV.
Thanks for the question!
Peter Johns that makes sense. Thanks for taking the time to explain!
Hi, thanks again for all your videos that are very helful! I learn in my vestibular class that the head should be flex 30° in the supine roll test but you don't seem to do that, what are your thoughts about that! Thanks!
I think anatomically it makes sense, since the horizontal canal is 30 degrees slanted down from anterior to posterior, but practically, since they are supine, probably doesn't make much difference. Hence, I try and make things as simple as possible for my learners. Supine roll test- lie them supine.
@@PeterJohns Thank you!
What about a vestibular weakness? Positional nystagmus may also be related to weakness. So wouldn't it be appropriate to perform VNG with Dix-Halpike + bi-thermal and bi-caloric assessment?
The most common cause of vertigo see in almost any clinical scenario is BPPV. Horizontal canal BPPV can be as high as 30 or 40% of cases of BPPV. If the nystagmus seen is typical of horizontal canal BPPV, and the patient is cured by a particle repositioning maneuver such as the Gufoni maneuver, then there is no indication for VNG or other vestibular tests.
Plz how to diffreniat between utricular and canalicular apogeotropic Hc Bpppv
Thank you doctor Johns, I have been diagnosed BPPV over a year and a half ago. I had several test done at Toronto East General with water in my year but they did not do a test (Dix Hallpike test) to determine which type of BPPV I had. A Physiotherapist I saw on 3 sessions applied his own manoeuvre which did a very violent shaking of my head with rolling me to the sides several times. I got someone better but I felt that I still had vertigo; in bed if I turn my head towards my right ear I felt a mild vertigo/dizziness. Occasionally I would do the Eppley manoeuvre on my own and would feel better however with the sense that I was not feeling perfectly well. This past week the vertigo returned again very intensely. When I do the Eppley manoeuvre starting on the right side I get pronounce nystagmus that eventually stops, turn to the left side and get mild nystagmus and when I do the turn looking down the nystagmus is severe and I cannot hold it and have to stop. I suspect that I might not have PC BPPV and maybe I have HC BPPV. Is there anyone in Toronto that would be able to perform the tests on me and apply the correct manoeuvre?
I don't know of anyone in particular in Toronto. I'd google "vestibular rehab" "Toronto" and find someone that way.
@@PeterJohns Thank you anyway.
Thanks Professor.
So it’s at last regardless of apogeotropic or geotropic- it’s Good ear towards ground turned 45degree and make the patient sit. Am I correct ?
No, this is not correct. Please watch it again and takes notes for you to refer to after you watch it.
Peter Johns
Oh yes .
Thanks for the reply.
I got it now after watching it again.
Horizontal nystagmus ? But Geotropic is vertical nystagmus , rightK?
The nystagmus of horizontal canal BPPV is horizontal. The direction of the nystagmus is from the perspective of the patient's head. So it is beating towards one ear or the other.
I got quite confused when performing the test on a real patient yesterday. would it be easier to understand it this way?
For GEOtropic nystagmus, the more intense side is the affected side
For APOgeotropic nystagmus, the more intense side is NOT the affected side
A year ago someone asked a similar question, and I responded as below:
Generally, in HC BPPV, when you do the supine roll test, one side will show nystagmus which is faster/more amplitude than the other side. To figure out the affected side, you can think it in two ways. In this video, I say that the more intense nystagmus is pointing towards the affected side. That is, the fast direction of the nystagmus is in the direction of the affected side. And that is true for both geotropic and apogeotropic.
The other way to say the same thing is: On the side that shows the more intense nystagmus, in geotropic, the affected ear is the downward ear. In apogeotropic, the affected ear is the upward ear. Hope this helps!
@@PeterJohns i like the 2nd interpretation ! for me that is easier to understand. thanks , i learnt so much from this channel and my patients have benefitted alot as well
Excellent video
Sir, You Deserve a Noble Price for Giving such Life Saving (Almost) Exercises...I have horizontal Nystagmus before taking Medicines and my Spinning has Reduce upto 60%. But the Floating Feeling is not going from inside me... Doctor has advice me to just to make Semont Maneuver to reduce it.. Can you please suggest me something which can help my Floating Feeling or It can be Imbalancing..
If, when you are lying down and the turning your head to so that your ear touches the bed,, you have horizontal nystagmus, then the Semont maneuver will not help you as it is for posterior canal BPPV. The video I made is for horizontal canal BPPV.
I tried Epley twice and realized it may be incorrect as condition persists.
Determined it may need Gufoni instead. Tried it out last evening. Hope vertigo will subside.
One question: how long does vertigo persists after Gufoni? Any advice, anyone?
To diagnose horizontal canal BPPV, the typical nystagmus must be observed. So I don't really know what you have, and I'd rather not comment further. Hope you feel better soon.
Fabulous videos and such a nice narrative
Thank you so much
@@PeterJohns Is it possible for a patient with no gaze evoked nystagmus to have a rebound nystagmus?
@@sankhashubhrachakrabarti2942 You might need to clarify that question before I attempt an answer.
@@sankhashubhrachakrabarti2942 I don't look for rebound nystagmus I must admit.
Apologies for not qualifying my question further. Is there a way to contact you by email etc?
Thank you so much for your wonderful videos. Your video on Dix-hallpike and Epley's cleared so much of my confusions. However, I do still have questions concerning this horizontal canal test. As I understand it, the intensity as well as the direction (apogeotropic or geotropic) of the nystagmus should rely on the location of the otolith in the canal. If it's located at the opposite side of the ampulla, it should create geotropic movement; and apogeotropic movement if it's located at the same side to the ampulla (coz it moves to the opposite direction of the ampulla when the head turns to the side of the troubled ear and creates inhibitory signals, right?)... However, the intensity of the nystagmus should be decided by the distance of the otolith from the base (vestibule), since the farthest position (such as at the tip of the canal) would create the biggest momentum and thus strongest stimulation to the receptors... Therefore I'm a bit confused when you said that the stronger side decides the laterality of the BPPV, since the way I understand it, the distance of the otolith is irrelavant to laterality. Is there something wrong in my understanding? Plus, how often do otoliths locate right at the tip of the canal, or right at the ampulla?
I hope my answer from your question from 2 days ago clears this up.
This is helping me a lot! but I don't understand why the affected ear of the second patient is the left one, If the Ny was more intense when he turns his head to the right. Isn't it an Apogeotropic Ny which it could means that is a cupulolithiasis?
You can either say:" For both geotropic and apogeotropic HC BPPV, on the side where the nystagmus is more intense, the direction of the fast phase of the nystagmus is pointing towards the affected ear"
Or you can say "For geotropic HC BPPV, on the side where the nystagmus is more intense, the downward ear is the affected ear. For apogeotropic HC BPPV, on the side where the nystagmus is more intense, the upward ear is the affected ear."
I saw that you already answer that. Thanks!! Hope you upload more videos, Thanks for teaching us with real life examples! this is a bit difficult to think for me! greetings from Buenos Aires, Argentina
@@emmanuelgrana5315 Glad you found my other reply! I'm curious, which of those two ways do you find easier to remember?
love you doc ..🧡
Is any medicine for cure this desease
The best cure are these maneuvers. If people are having trouble tolerating the maneuvers, an anti-emetic can be given before. Vit D may play a role in prevention of BPPV.
Thank you. U r amazing
Thanks doc
Thanks a lot 🙏
Thank you
Thank you!!!!
wonderful explanation sir
Thanks!
great ..👍👍
Super videos; ty doc;
Hi, I’m one of the followers of your excellent videos on BPPV. I’m somewhat confused about the determining the affected side in ageotropic horizontal canal BPPV in supine roll test. In your first video (ua-cam.com/video/iOJOArGmepM/v-deo.html) on the horizontal canal BPPV you mentioned the affected side, the side with less intense nystagmus while in this video the side with more intense nystagmus like the geotropic type.
Which one is correct?
I say the same thing but in different ways I think. Two ways to think of it. Yes, in HC BPPV, one side usually has a stronger nystagmus and symptoms than the other side.
So one way to think of it is: with the head turned towards the stronger nystagmus and patient symptoms, in geotropic, the affected ear is the downward ear. In apogeotropic, the affected ear is the upper ear.
The way I explained it here was: in both geotropic and apogeotropic, the nystagmus is "pointing" towards the affected ear. So in geo, it points down, and in apogeo, it points upward.
Hope this helps.
@@PeterJohnsThank you I get it👌