Just finished ED shift here in Singapore. 64yo male came in for severe, sudden vertigo when he woke up and looked to the left. Pretty sure it's BPPV. No vertigo during initial consult (good candidate for BPPV, not HINTS+) Dix Hallpike done. No vertical/rotational nystagmus, but my junior doctor noticed a subtle horizontal nystagmus. Hurriedly watched your videos on Horizontal Canal BPPV and went back again to the patient: Supine Roll (left): positive for Geotrophic HC BPPV! Hurriedly watched your video again for the treatment and did the Barbecue/Lempert Roll Maneuver. Also watched the Gufoni maneuver just in case. In the end, only the barbecue roll maneuver was enough. Repeated the Supine Roll test, and now it's negative. Thank you Dr Johns! You make me excited to see vertigo patients!
I am a family medicine resident in Greece, currently finishing my training in a primary care setting. Within a year, I have cured about 15 to 20 patients presenting with posterior canal BPPV and every time patients are extremely surprised and impressed, when I test again with the Dix-Hallpike test and no vertigo is triggered! I always recommend your videos to the rest of my colleagues. Thank you for providing all this content for many others out there, for a medical topic many family doctors are afraid to encounter.
Another gem! I (a PT/physio) am going to be giving an hour talk on BPPV to family practice residents in about a month. Hoping it's ok to reference your content!
Fantastic! When I tell learners that the nystagmus of PCBPPV is vertical upwards I almost universally get a skeptical look and it appears that they begin looking around the ED for an actual doctor 😂
Haha! I remember showing a classic positive DHT to an older ED doc and him going "ooooo....vertical.... that's bad!" I also heard a medical student say that she saw a case of BPPV with another doc and when the nystagmus was vertical, the patient had to have a CT head "just to be sure". Ouch!
@@olympiashorts I heard a neurologist was referred a patient and the referring team said the HINTS exam was "negative". The neurologist asked "just to be clear, what did the head impulse test show?" The answer: "It wasn't done, so it was negative". Doh!
I recently consulted a patient who was admitted to neurology with acute vestibular syndrome with spontaneous left-beating horizontal nystagmus, positive HIT to the right, no skew, no other pathologies because „repetitive Semont manever wasn’t effective”.
@@michamachaa8775 I've seen a woman admitted to neurology for vertigo, had an MRI, and sent home. But was still dizzy moving around! I saw her and diagnosed her with horizontal canal BPPV. Cured her, sent her home.
@PeterJohns Dear Dr Johns, if patient feels like they are moving themselves, vs the room spinning. Can this be of significant? Does it give us a clue of central/peripheral? Many thanks
I'd like your input on a case I had today. Keep in mind, I'm a physical therapist with no formal vestibular education, just self-taught. I had a woman in her thirties come to the hospital today. She had had a little over a week long of a migraine level headache that she reported as feeling like sinus but no other URI symptoms. She has no migraine hx other than this.Towards the tail end of her bout with the migraine, she started to have vertiginous symptoms such as being unsteady and feeling like she had been drinking or a rocking sensation. There was no spinning sensation. She was able to walk, work and go about her daily life, but she did have one fall as a result of this. She saw ENT yesterday who couldn't find any inner ear cause for her symptoms. They ended up sending her to the hospital to check for a posterior circulation CVA. CT and MRI were negative. During my assessment, She had no resting nystagmus but with left and right unfocused gaze, she had a horizontal nystagmus that seemed to have a little bit of a torsional component, different than what I'm used to seeing with dix hallpike. It was faster with gaze to one side than the other. I did not perform a hints exam since there was nystagmus. I wasn't sure if I should still do a supine roll test or not but I performed it and when the left side was tested she had a horizontal nystagmus. The right side was either negative or much less severe. I can't diagnose but my gut thought was probably vestibular neuritis. I did not however know how to rule out horizontal canal bppv. I ended up asking for a neurology consult and they had no clue and didn't see the nystagmus that I saw. I ended up asking for an outpatient vestibular consult and thankfully they gave the lady steroids and meclizine. What's your thoughts on the diagnosis and anything else that I should or should not have done? Its soo frustrating to see these people go through multiple tests and multiple disciplines and not walk away with an answer
I believe you are saying that you saw nystagmus when the patient looked left and right, which was unidirectional. Horizontal with a slight torsional component. It was worse one side verses the other, but did not change direction. I am puzzled why you feel you can't do the HINTS exam if they have nystagmus. This is where HINTS is indicated. Look at this video. I was able to diagnose this woman with vestibular neuritis whom I only saw the nystagmus in one direction, and I need to remove fixation to see it clearly. ua-cam.com/video/eGcUTfeHvZg/v-deo.html&ab_channel=PeterJohns
I'm a PT with an interest in vestibular rx but no formal education other than self-taught. If you see a nystagmus with both left and right Dix Hall Pike but one side is significantly more pronounced, do you assume that they have a positive bilateral test? It can be difficult sometimes to tell the direction of torsion, especially if they are not able to open their eyes fully. Also, second question, what is your best way to differentiate between bppv and vestibular neuritis? I've seen patients feel funny with Dix testing but there was no nystagmus but then when I check horizontal gaze they will get nystagmus. The hospital I work at immediately goes into stroke protocol mode no matter what and actually will not even allow me to do Dix Hall Pike until they have had a negative CT
Sorry to hear you practice in such a non-evidence based environment. What kind of nystagmus do you see on both left and right Dix-Hallpike test? Are you familiar with horizontal canal BPPV? ua-cam.com/video/VRjRTnIw9YE/v-deo.html Vestibular neuritis will almost always have nystagmus at rest, while BPPV will almost never it. Look carefully for nystagmus as I show in this video. ua-cam.com/video/eGcUTfeHvZg/v-deo.html Doing the DHT on patients with vestibular neuritis may make a patient feel more dizzy and make a non-specific worsening or bringing out some horizontal nystagmus.
You will learn a ton on Dr. Johns' channel. Another resource on UA-cam that is more PT-centric (hope it's ok I plug this channel here) is Balancing Act Resources : www.youtube.com/@BalancingActResources If you have access to MedBridge, I highly suggest the courses by Jeff Walter, DPT (he has videos on YT also, I believe, but the Medbridge courses give you CE credit)
TY! I will definitely continue watching your videos and will check out that video series by the PT also. The medbridge series is on my list too. I totally need further education but also need to get a better grasp on the ordering the different assessments that I do.
Recently I had a BPPV patient in my clinic. She presented with one episode of dizziness during night when turning over towards the right. Anti clockwise rotational spinning sensation was described. On dix hallpike to the left she presented with vertical torsional nystagmus towards left and horizontal nystagmus towards left, with dizziness. On the right dix hallpike, she got more dominant horizontal nystagmus towards left and way more dizziness. Both the sides had nystagmus and dizziness for more than 60 second. Is the more likely canals involved both the Left Posterior SCC and Left Horizontal SCC cupulolithiasis? Or did I get it wrong? I did not catch anything unusual regarding spontaneous nystagmus or hints exam.
Hard to say. I would have done a supine roll test. It may have very well been multi-canal BPPV though. Standard approach is to treat the more symptomatic canal. I don't have a lot of practical experience with multi-canal BPPV though.
@@PeterJohns Thank you Peter. I did proceed with supine roll test. However, same result with the horizontal nystagmus. Anyways, thanks a lot for your help. Your videoes has helped me a lot in the start up of understanding and treating people with BPPV. I will then start with treatment of the more symptomatic side and see how the patient responds.
So am i right to say: 1) if the patient has vertical resting nystagmus then a hints can be skipped as the pt is already so concerning and will need ct? And 2) the patient who has continuous vertigo and shows no resting nystagmus but has provoked vertical nystagmus is concerning ?
1. Yes, vertical nystagmus at rest is almost always a central cause (very rarely, inferior vestibular neuritis can do it). CT head or CT angio is has very poor sensitivity for posterior circulation strokes, which are the most common central causes of vertigo. So a negative CT head by no means should be reassuring if the patient has vertical nystagmus at rest. The gold standard is a delayed MRI. 2. Many patients with BPPV will complain of a lesser continuous dizziness and have no nystagmus at rest. Patients without nystagmus at rest are OK to do the Dix-Hallpike or supine roll test on, and if the nystagmus is consistent with either posterior or horizontal canal BPPV, then the diagnosis is made. Patients who complain of dizziness and have no resting nystagmus but have a new objective difficulty walking are at high risk of stroke. But it's important to look carefully for nystagmus at rest in patient with complaints of persistent dizziness. Sometimes you only see it if you remove fixation, which can be easily accomplished with a blank piece of paper. ua-cam.com/video/eGcUTfeHvZg/v-deo.html
It seems there may be far too many healthcare professionals who tend to be eager to believe something is or is probably an inner ear issue when there is no evidence of a stroke in MRI when in reality it is Ataxia.
@@PeterJohnsI work in an Australian ED and I’m constantly amazed by the number of dizzy patients referred for CT and further neuro work up /admission by clueless ED docs who can’t do a proper evaluation of the dizzy patient. You should visit down under and do some teaching 😂
Just finished ED shift here in Singapore. 64yo male came in for severe, sudden vertigo when he woke up and looked to the left. Pretty sure it's BPPV. No vertigo during initial consult (good candidate for BPPV, not HINTS+)
Dix Hallpike done. No vertical/rotational nystagmus, but my junior doctor noticed a subtle horizontal nystagmus.
Hurriedly watched your videos on Horizontal Canal BPPV and went back again to the patient:
Supine Roll (left): positive for Geotrophic HC BPPV!
Hurriedly watched your video again for the treatment and did the Barbecue/Lempert Roll Maneuver. Also watched the Gufoni maneuver just in case.
In the end, only the barbecue roll maneuver was enough. Repeated the Supine Roll test, and now it's negative.
Thank you Dr Johns! You make me excited to see vertigo patients!
Glad to hear it! Keep it up and become a vertigo champion! We need more of them in emergency medicine.
I am a family medicine resident in Greece, currently finishing my training in a primary care setting. Within a year, I have cured about 15 to 20 patients presenting with posterior canal BPPV and every time patients are extremely surprised and impressed, when I test again with the Dix-Hallpike test and no vertigo is triggered! I always recommend your videos to the rest of my colleagues. Thank you for providing all this content for many others out there, for a medical topic many family doctors are afraid to encounter.
That is very wonderful to hear. The highest kind of compliment is to hear that you have learned to help people. Thank you!
Excellent information. I also have 40 years of practice and never heard this before.
Another gem! I (a PT/physio) am going to be giving an hour talk on BPPV to family practice residents in about a month. Hoping it's ok to reference your content!
Always well done, Dr. Johns. (and with massively well known Dr. Glaucomflecken, no less).
Fantastic! When I tell learners that the nystagmus of PCBPPV is vertical upwards I almost universally get a skeptical look and it appears that they begin looking around the ED for an actual doctor 😂
Haha! I remember showing a classic positive DHT to an older ED doc and him going "ooooo....vertical.... that's bad!" I also heard a medical student say that she saw a case of BPPV with another doc and when the nystagmus was vertical, the patient had to have a CT head "just to be sure". Ouch!
@@PeterJohns my favorite is when the learner presents a patient on whom they have (proudly) performed both a DHT and a HINTS, yikes.
@@olympiashorts I heard a neurologist was referred a patient and the referring team said the HINTS exam was "negative". The neurologist asked "just to be clear, what did the head impulse test show?" The answer: "It wasn't done, so it was negative". Doh!
I recently consulted a patient who was admitted to neurology with acute vestibular syndrome with spontaneous left-beating horizontal nystagmus, positive HIT to the right, no skew, no other pathologies because „repetitive Semont manever wasn’t effective”.
@@michamachaa8775 I've seen a woman admitted to neurology for vertigo, had an MRI, and sent home. But was still dizzy moving around! I saw her and diagnosed her with horizontal canal BPPV. Cured her, sent her home.
@PeterJohns Dear Dr Johns, if patient feels like they are moving themselves, vs the room spinning. Can this be of significant? Does it give us a clue of central/peripheral? Many thanks
I'd like your input on a case I had today. Keep in mind, I'm a physical therapist with no formal vestibular education, just self-taught. I had a woman in her thirties come to the hospital today. She had had a little over a week long of a migraine level headache that she reported as feeling like sinus but no other URI symptoms. She has no migraine hx other than this.Towards the tail end of her bout with the migraine, she started to have vertiginous symptoms such as being unsteady and feeling like she had been drinking or a rocking sensation. There was no spinning sensation. She was able to walk, work and go about her daily life, but she did have one fall as a result of this. She saw ENT yesterday who couldn't find any inner ear cause for her symptoms. They ended up sending her to the hospital to check for a posterior circulation CVA. CT and MRI were negative. During my assessment, She had no resting nystagmus but with left and right unfocused gaze, she had a horizontal nystagmus that seemed to have a little bit of a torsional component, different than what I'm used to seeing with dix hallpike. It was faster with gaze to one side than the other. I did not perform a hints exam since there was nystagmus. I wasn't sure if I should still do a supine roll test or not but I performed it and when the left side was tested she had a horizontal nystagmus. The right side was either negative or much less severe. I can't diagnose but my gut thought was probably vestibular neuritis. I did not however know how to rule out horizontal canal bppv. I ended up asking for a neurology consult and they had no clue and didn't see the nystagmus that I saw. I ended up asking for an outpatient vestibular consult and thankfully they gave the lady steroids and meclizine. What's your thoughts on the diagnosis and anything else that I should or should not have done? Its soo frustrating to see these people go through multiple tests and multiple disciplines and not walk away with an answer
I believe you are saying that you saw nystagmus when the patient looked left and right, which was unidirectional. Horizontal with a slight torsional component. It was worse one side verses the other, but did not change direction. I am puzzled why you feel you can't do the HINTS exam if they have nystagmus. This is where HINTS is indicated.
Look at this video. I was able to diagnose this woman with vestibular neuritis whom I only saw the nystagmus in one direction, and I need to remove fixation to see it clearly. ua-cam.com/video/eGcUTfeHvZg/v-deo.html&ab_channel=PeterJohns
Thank you for the informative clip. Could you please upload a video clip about Light Cupula? Thank you!
You know, light cupula is not something I have a good grasp on. Someone with experience diagnosing it will have to make a video.
I'm a PT with an interest in vestibular rx but no formal education other than self-taught. If you see a nystagmus with both left and right Dix Hall Pike but one side is significantly more pronounced, do you assume that they have a positive bilateral test? It can be difficult sometimes to tell the direction of torsion, especially if they are not able to open their eyes fully. Also, second question, what is your best way to differentiate between bppv and vestibular neuritis? I've seen patients feel funny with Dix testing but there was no nystagmus but then when I check horizontal gaze they will get nystagmus. The hospital I work at immediately goes into stroke protocol mode no matter what and actually will not even allow me to do Dix Hall Pike until they have had a negative CT
Sorry to hear you practice in such a non-evidence based environment. What kind of nystagmus do you see on both left and right Dix-Hallpike test? Are you familiar with horizontal canal BPPV? ua-cam.com/video/VRjRTnIw9YE/v-deo.html Vestibular neuritis will almost always have nystagmus at rest, while BPPV will almost never it. Look carefully for nystagmus as I show in this video. ua-cam.com/video/eGcUTfeHvZg/v-deo.html
Doing the DHT on patients with vestibular neuritis may make a patient feel more dizzy and make a non-specific worsening or bringing out some horizontal nystagmus.
You will learn a ton on Dr. Johns' channel. Another resource on UA-cam that is more PT-centric (hope it's ok I plug this channel here) is Balancing Act Resources : www.youtube.com/@BalancingActResources
If you have access to MedBridge, I highly suggest the courses by Jeff Walter, DPT (he has videos on YT also, I believe, but the Medbridge courses give you CE credit)
TY! I will definitely continue watching your videos and will check out that video series by the PT also. The medbridge series is on my list too. I totally need further education but also need to get a better grasp on the ordering the different assessments that I do.
Recently I had a BPPV patient in my clinic. She presented with one episode of dizziness during night when turning over towards the right. Anti clockwise rotational spinning sensation was described. On dix hallpike to the left she presented with vertical torsional nystagmus towards left and horizontal nystagmus towards left, with dizziness. On the right dix hallpike, she got more dominant horizontal nystagmus towards left and way more dizziness. Both the sides had nystagmus and dizziness for more than 60 second. Is the more likely canals involved both the Left Posterior SCC and Left Horizontal SCC cupulolithiasis? Or did I get it wrong? I did not catch anything unusual regarding spontaneous nystagmus or hints exam.
Hard to say. I would have done a supine roll test. It may have very well been multi-canal BPPV though. Standard approach is to treat the more symptomatic canal. I don't have a lot of practical experience with multi-canal BPPV though.
@@PeterJohns Thank you Peter. I did proceed with supine roll test. However, same result with the horizontal nystagmus. Anyways, thanks a lot for your help. Your videoes has helped me a lot in the start up of understanding and treating people with BPPV. I will then start with treatment of the more symptomatic side and see how the patient responds.
So am i right to say:
1) if the patient has vertical resting nystagmus then a hints can be skipped as the pt is already so concerning and will need ct? And
2) the patient who has continuous vertigo and shows no resting nystagmus but has provoked vertical nystagmus is concerning ?
1. Yes, vertical nystagmus at rest is almost always a central cause (very rarely, inferior vestibular neuritis can do it). CT head or CT angio is has very poor sensitivity for posterior circulation strokes, which are the most common central causes of vertigo. So a negative CT head by no means should be reassuring if the patient has vertical nystagmus at rest. The gold standard is a delayed MRI.
2. Many patients with BPPV will complain of a lesser continuous dizziness and have no nystagmus at rest. Patients without nystagmus at rest are OK to do the Dix-Hallpike or supine roll test on, and if the nystagmus is consistent with either posterior or horizontal canal BPPV, then the diagnosis is made. Patients who complain of dizziness and have no resting nystagmus but have a new objective difficulty walking are at high risk of stroke. But it's important to look carefully for nystagmus at rest in patient with complaints of persistent dizziness. Sometimes you only see it if you remove fixation, which can be easily accomplished with a blank piece of paper. ua-cam.com/video/eGcUTfeHvZg/v-deo.html
It seems there may be far too many healthcare professionals who tend to be eager to believe something is or is probably an inner ear issue when there is no evidence of a stroke in MRI when in reality it is Ataxia.
Haven't seen a lot of that myself.
Australian 😂
Yes, oddly both videos came from down under.
@@PeterJohnsI work in an Australian ED and I’m constantly amazed by the number of dizzy patients referred for CT and further neuro work up /admission by clueless ED docs who can’t do a proper evaluation of the dizzy patient. You should visit down under and do some teaching 😂