IMPORTANT!!! You should first screen your dizzy patients for central features that would not be expected in vestibular neuritis and may signify a central cause such as stroke. And they are: New Significant headache or neck pain Focal weakness or paresthesias Any dangerous D's - diplopia, dysarthria, dysmetria, dysphonia, dysphagia Vertical nystagmus at rest (not during the Dix-Hallpike test) Inability to walk unaided You should carefully consider a central cause if your patient has any of these central features, irregardless of their HINTS exam findings.

Best video ever to describe Vertigo. Thank you!!!

such an important exam but no one teaches that in med school.. thanks a lot for your channel and educational videos! Excellent editing and transition from lecture slides to real pt exams. All the info sticks in my brain so smoothly especially with multiple patients scenarios.

That was once of the best educational videos I have ever seen.

great presentation, appreciate the examples inculded.

Brilliantly explained. Thanks a ton!!

Dear Dr Jones, I love your clarity and schema, many thanks. What about Meniere's Disease where we can find an ABNORMAL finger rub test but it is definitely a peripheral origin vertigo?

@PeterJohns

5 жыл бұрын

First episode of Meniere's is difficult to differentiate from stroke, and it would be wise to rule out a central cause. In someone who has an established history of Meniere's disease then and presents with an acute episode of vertigo with nystagmus, if there are no other features to suggest a stroke, I would presume the hearing loss is likely due to the Meniere's.

Excellent instructional tutorial video.

Well documented video. Many thanks for demonstrating the technique

I have had patients in the past who are +ve for DHP but it produces a slow torsional nystagmus for around 30 seconds which is stubborn regarding treatment. This could be cupulothiasis, do you have any different treatment variations for this? I have tried using Brandt Daroff to accelerate progression to make treatment with epley more successful.

Beautifully explained & illustrated

As great an explanation as one could ask for. Thank you

Great videos, very helpful. I assume even later down the line, weeks after the initial episode, if they have direction changed nystagmus on gaze it would equal possible central pathology?

@PeterJohns

6 жыл бұрын

Any time you see nystagmus where the fast component of the nystagmus changes direction when they look to the left or right, the cause of the nystagmus is central, so yes.

By far, you are the best, thank you so very much.😍

U r amazing. Thanks .

vety helpful video, thanks

amazing !! Thank you

awesome video thank you

👌👌👌

excellent

Dr. Johns, curious how you document the results of the HINTs+ in the chart. If it is indicative of a peripheral cause do you write NORMAL vs ABNORMAL if indicative for central cause. I always question how I should document this. Thanks for a great tutorial.

@PeterJohns

6 жыл бұрын

Excellent question! If it is indicative of a peripheral cause (eg a right vestibular neuritis) then I would document as follows: "Spontaneous nystagmus to left, doesn't change direction with rightward gaze, no skew deviation, HIT abnormal when head turned to right, normal finger rub rest, therefore overall HINTS plus = peripheral. Likely a right vestibular neuritis." To write merely HINTS plus normal or abnormal is both unclear and doesn't indicate you correctly interpreted the HINTS plus exam. It would be like having a patient with an anterior stroke who presents with dysphasia and hemiplegia and simply writing on the physical exam as "stroke". Thanks again for the question!

@Sharpbevel

6 жыл бұрын

Thanks so much for the great reply!

@PeterJohns

6 жыл бұрын

I edited a mistake, I had the word gaze instead of change. :)

Thanks for the excellent and very useful video. I recommend you to all my trainees! Could you explain why you stipulate the duration of symptoms as hours to days? Is there some other duration of symptoms that implies other pathology?

@PeterJohns

9 ай бұрын

Yes, it would be unusually for a vestibular neuritis to last just a few hours. Sort of like seeing a Bell's palsy lasting only a few hours, really doesn't happen. Other diagnoses could come into play. Vestibular migraine can last a few minutes to a few days. And Meniere's disease typically lasts for several hours (and is 10 times less common than vestibular migraine). The hallmark of VM and Meniere's is multiple recurrent attacks. The other things is that BPPV patients sometimes endorse having a constant dizziness which is mild. These patients won't have nystagmus at rest, only with positional testing. Except for a less common phenomena of pseudo-spontaneous nystagmus in horizontal canal BPPV. Some patients with small cerebellar stroke or a posterior circulation TIA could have shorter than 24 hours of dizziness. These patients would usually (but not always) screen positive for central features. as listed in the pinned comment. These can be difficult patients to sort out, but I did make a video about my suggested approach. kzread.info/dash/bejne/a5Ojkqdqed3Zc7A.html

Great Videos Doctor. But new Hearing loss is not always a Central-problem. For example a Patient with meniere's disease you can find also here Nystagmus with Hearing loss (primarily affects low frequencies). Also in Ramsy-Hunt-Syndrom

@PeterJohns

6 жыл бұрын

True, but Meniere's disease had recurrent episodes, which would lead you to the diagnosis. It is true that the first episode of Meniere's could be HINTS plus-central, and thus mandate diagnostic imaging and referral to neurology, but first presentation of Meniere's is quite a bit rarer than vestibular neuritis or stroke. Ramsay -Hunt would likely present with vesicles in the external ear and facial nerve weakness which would be a clue to the diagnosis.

@jessicas3496

4 жыл бұрын

Peter Johns How would you differentially dx acute labyrinthitis vs AICA stroke as they would both have would both have +HIT and acute hearing loss?

Informative. Sir can you please give explanation behind these results

@PeterJohns

6 ай бұрын

Can you be more specific in your question?

What if you can't see any nystagmus whatsoever?

@PeterJohns

5 жыл бұрын

Great question. If they have ongoing, continuous dizziness for the past few hours or day or two , and nausea/vomiting, and some difficulty with gait, and you DON'T see nystagmus, then they are very unlikely to be suffering from vestibular neuritis and I'd be worried about a cerebellar stroke without nystagmus. So I'd evaluate them for a stroke. Really, HINTS plus is to distinguish vestibular neuritis from a posterior circulation stroke that is presenting just like vestibular neuritis, or "pseudo-vestibular neuritis" as it is sometimes referred to. How common does this occur? No one really knows, but you can use the power of HINTS plus to send home the classic cases of vestibular neuritis and not be worried about "pseudo-vestibular neuritis".

@stuartsmith4223

Жыл бұрын

But counterintuitively I think you strongly indicate that spontaneous or gaze evoked nystagmus is ‘entry criterion’ for the HINTS test?

Thanks for such a great informative video. But what about acute labyrinthitis? There will be new hearing loss and the lesion is also peripheral.

@PeterJohns

7 ай бұрын

Absolutely true. But it’s much less common than vestibular neuritis. How common it is vs a dizzy stroke is not well known.