Why you shouldn't do the HINTS exam on patients who DON'T have nystagmus
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- Опубликовано: 25 июн 2024
- Why you shouldn't do the HINTS exam on patients who DON'T have nystagmus, and why you shouldn't do the Dix-Hallpike test on patients WITH nystagmus
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I really appreciate the screenshots of the evidence - based papers. Thank you for all the vertigo work you share to all of us, much appreciated
Thank you Peter , your videos are very informative and easy to digest
Absolutely brilliant videos, I wasn't even familiar with the HINTS+ exam before watching them. This will be a very valuable tool for a young physician working in the ER. Thank you very much for your educational work Dr. Johns!
Thank you so much for your amazing videos. They are very helpful.
Thank you professor. Very crucial pearls. I have previously made the first mistake - doing the HINTS on a patient with symptoms compatible with vertigo, and thinking the HINTS was NORMAL, erroneously considered a central cause, for a patient WITHOUT Nystagmus
Thank you Doctor, very detailed references indeed,
thank you, this is such a great video!
very good, thank you so very much.👍👍👍
hello sir. this is dr abhinav , ENT surgeon from india. this video was very useful for me. thank you so much for posting.kindly share more videos
Thanks for these videos. They have cleared up my understanding a LOT about this topic. The only real question that I have is about nystagmus. Constant nystagmus I get, but I thought that gaze evoked nystagmus could be a normal variant. Thanks.
There is a lot of confusion about the nomenclature of vertigo. Gaze evoked nystagmus is nystagmus that is produced when the patient looks off center. Mostly, it's pathologic, either caused by a peripheral or central cause (most commonly vestibular neuritis or posterior circulation stroke. But there is a normal variant called end gaze nystagmus, (or end point nystagmus) shown in this video which I just published 12 days ago. ruclips.net/video/2Ej3jwgvwMU/видео.html
Dr. Johns,
Thank you for this great video! What are the statistics of likelihood for central pathology with each additional HINTS finding? Can one of the HINTS Plus tests be more sensitive or specific than an MRI for a central diagnosis?
Normal Head Impulse Test: LR ____
Bidirectional Nystagmus: LR ____
Abnormal Test of Skew: LR ____
Hearing Loss: LR ____
Have you read the "Update on HINTS Plus, With Discussion of Pitfalls and Pearls" in the Journal of Neurologic Physical Therapy in the April 2019 Issue?
The best place to find the answer for that is in the paper "HINTS outperforms ABCD2 to screen for stroke in acute continuous vertigo and dizziness" by Newman-Toker et al. in Academic Emergency Medicine 2013. Have a look at taht and if you have questions I'll try and answer them.
Peter, this is brilliant indeed!!. Dr. Neumann Toker, the so called expert in vertigo got me really confused.. I was in the same dilemma. If I did a HINTS exam on a patient with BPPV - I will get a normal result and will then think they have a central cause... but thanks for that clarification.. Do you recommend any algorithm to use to evaluate patients presenting with vertigo in ED?. thanks for your help.
Thanks for your kind words. David Newman-Toker never advised people to do the HINTS exam on patients who did not have nystagmus, or did not have continuous nystagmus. Have your read my paper in the CMAJ? It is open access. www.cmaj.ca/content/192/8/E182
Is that the bayeux tapestry?
First of all, congratulations for the amazing video. I’m a brazilian doctor and I am loving all this. If I may, I wold like to make a question. In your opinion and experience the HINTS exam should exclusively be done only BEFORE give any kind of simptomatic drug for the patient? Can Anti-vertigo drugs “change” in a dangerous way the results of the HINTS exame?
An interesting question, and I'm fairly certain this has not been studied. But my feeling would be that as long as the patient still has nystagmus at the time of the HINTS exam, I think the results would be valid whether they had received a vestibular sedative medication or not. Thanks for the question!
Hi, I am a PT and we sometimes see suppression of nystagmus when patients have had meclizine, so we find it sometimes more accurate to test them (at least for BPPV) prior to any vestibular suppressants. not sure if the same would hold true for the HINTs exam.
Sir how do i deal with the PCS problem?
Thanks for a great lecture. Is it possible that patient have BPPV but all of the maneuvers is without nystagmus.
Do you mean a patient feels vertigo but no nystagmus seen? Or do you mean the patient has no vertigo or nystagmus during the Dix-Hallpike Test?
I see patients getting Dix HallPike testing all the time with nystagmus. Do you get a lot of pushback from those providers who believe it’s an appropriate test? Thanks for the great video Dr. Johns.
Thanks for the question. Vertigo has been taught poorly for decades. As a result, many clinicians have little understanding of vertigo and are painfully aware of it. So when I explain my approach to vertigo, the most common reaction I see if the feeling that a light has just gone on in their head, and they are now looking forward to seeing vertigo patients because they understand it better now.
Love this summary and perspective! Thank you for sharing. Do you ever complete Choung’s test/head flexed test in clients who present w spontaneous nystagmus to check for pseudospontaneous nystagmus? In my PT world, I find this helpful, but my clientele are way different than yours most of the time.
@@conveyorbeltz1 Thanks Andy! I didn't know the Bow and Lean test had that eponym. Because Lord knows, vertigo could some more eponyms! LOL! So yes, I do check for spontaneous vs pseudo-spontaneous nystagmus and use the Bow and Lean test when the supine roll test is not so clear. In the world that I teach others about vertigo, just mentioning that horizontal canal BPPV exists and is common is a revelation. I plan on making a deeper dive into HC BPPV in the future and talk about these things, but for now I'm keeping it basic so I don't lose too many people along the way.
Peter Johns lol! Ugh! Yes...Bow and Lean... how quickly my mind resorts to the original terminology learned. I love your work! I do not commonly see clients in early onset acute vestibular syndrome, but will see spontaneous nystagmus only with fixation blocked (maybe days or weeks after AVS onset). Pseudospontaneous nystagmus has been a passion of mine as it kind of changes the rules for timing of BPPV and when combined with the Gufoni maneuver, can sometimes provide comfort a little quicker than the Lempert 360° barbecue roll (all names I am aware of included for lateral canal canalithiasis...lol). You are my latest vestibular hero! Keep up the great work!!
although, BPPV sometimes can occur soon after neuritis/ they can present together. but in my PT practice (outpatient clinic) i typically see them after most of the neuritis has improved and they have symptoms more consistent with BPPV. or if I see them acutely (in the hospital), if you start moving them around to test/treat for BPPV, they will get really sick and you have unnecessarily made them miserable!
Hi. Why should we only do it on someone with hours of these symptoms? It seems the studies and papers that were mentioned all did not include an "hour" component (except for the one that gave a definition of 24 hours). If it's constant and more than just several minutes, would HINTS still fail us if we used it?
If it's just a few minutes, and now the symptoms and nystagmus have resolved, HINTS is not a useful test. Because vestibular neuritis doesn't last that short a period, so it's off the differential diagnosis.
I basically never see a patient in the emergency department where the patient has had constant vertigo for only several minutes. By the time they took to get to the emergency department, and wait to see me, it's going to be an hour at least. Unless of course they had something else that made them more urgent, like weakness on one side or slurred speech or double vision. But those people don't need HINTS either, because you don't get that with vestibular neuritis. Thanks for the question!
Thanks for the video! When we consider nystagmus, is gaze evoked implied?
Maybe just expand on your question a little so I know what you're asking.
Ok , sorry. When the video instructs to assess for nystagmus, is it most commonly end gaze nystagmus that we are looking for? For example, it does not need to be a spontaneous nystagmus... I hope that makes sense@@PeterJohns
I@@drwrightswrightlife886 I have evolved in my terminology around this. You can do the HINTS exam on patients with constant dizziness AND nystagmus seen when they are at rest. This would include patient who have spontaneous nystagmus (nystagmus seen when the patient is looking straight ahead) or if it's only seen when the patient is asked to look 30 degrees off to the left or right. So nystagmus "seen at rest" would not include nystagmus which is brought on by positional testing, such as the Dix-Hallpike or supine roll test.
It also would not include end gaze (or also called end point) nystagmus, which is seen when some people are asked to gaze as far as they can to the left or right. End gaze nystagmus is not pathological and is a normal variant seen in some people.
When I started making videos years ago, "gaze evoked nystagmus" seemed to be used by many vertigo experts (David Newman-Toker, Jorge Kattah, Jonathan Edlow) as meaning nystagmus that wouldn't be seen with the patient looking straight ahead, only when the patient gazed 30 degrees left or right. And this is what I meant by the term in this video. This kind of nystagmus can be seen in milder vestibular neuritis after a few days and also in dizzy strokes. So HINTS would be useful in these cases as the VN would have an abnormal HIT and dizzy strokes would have a normal HIT, except for AICA strokes, which would be picked up the bedside test of hearing (HINTS plus)
Increasingly it seems vertigo experts are using "gaze evoked nystagmus" to refer to nystagmus that changes direction depending on which way the patient is looking. This kind of nystagmus is a HINTS central sign, and would indicate a central cause for the patient dizziness. In my previous videos, I referred to it as "bidirectional nystagmus" but I have changed to the longer but less ambiguous term of "nystagmus that changes direction with gaze" or "nystagmus that beats to the left when looking left, and beats to the right when looking right.
I think this answer your question, but if it doesn't, let me know.
@@PeterJohns It does answer my question, thank you for your time and your response!
Can you please expand on those with constant dizziness without any nystagmus? What testing do you do in office?
Watch this video at this time stamp, and let me know if you have any questions after that. I used to work in an emergency department (now retired). Never worked in an office. ruclips.net/video/MgzhbsxzBdA/видео.html
If a patients history is classic for BPPV, will the Dix Hallpike test sometimes not provoke nystagmus/dizziness? And if it does not, where does this leave the clinician in his management "algorithm"?
Good question. First of all, perform a supine roll test, looking for horizontal canal BPPV. See this video ruclips.net/video/VRjRTnIw9YE/видео.html Then, if this is negative, perform the Dix-Hallpike test again. One study showed that patients with a good story for BPPV but a negative DHT, if you repeated it, half the patients who were negative the first time are positive the second time. If all this is negative, the patient may be a spontaneous resolution of BPPV, which can happen. If they are now asymptomatic, and the story is entirely consistent with BPPV, the patient can be sent home and told to seek attention if they have recurring symptoms, or follow up with a health care provider. Hope this helps.
@@PeterJohns That does help! As always, thank you.
Hi Peter, thanks for the great video. Is the Dix-Hallpike pathognomonic for BPPV? I had a patient that had previously been diagnosed with BPPV with a reasonably response to the Epley that presented with headache and vertigo. The vertigo was present most of the time (not necessarily always on head movement). She had a positive Dix-Hallpike to the right, but a poor reponse to the Epley. Could vestibular migraine give a positive DH? Thanks
Do you recall the kind of nystagmus that your patient had? A Dix-Hallpike test is only diagnostic for posterior canal BPPV if the characteristic vertical upward and rotatory nystagmus towards the downward ear is seen. See my video ruclips.net/video/88dPK4_8kj8/видео.html Vestibular migraine patients will not show this pattern of nystagmus during the DHT, unless they in fact have posterior canal BPPV, which as it turns out, they are more susceptible to.
@@PeterJohns Yes, the nystagmus was pretty typical for BPPV on the right side. Its very interesting that patients with vestibular migraine are more susceptible to BPPV. I wonder if this patient had both. Thanks for the speedy reply.
I think if you induce the nystagmus and vertigo with DHP in a BPPV patient (episodic,
No. If you were to perform a head impulse test while a patient with BPPV was having nystagmus that was induced by the Dix-Hallpike test, the patient would have not have an abnormal head impulse test. The abnormal catch up saccade in vestibular neuritis is because the patient with vestibular neuritis has a loss of vestibular function, which impairs the vestibulo-ocular reflex. In BPPV, there is no impairment of the VOR. So if you did as you proposed (which I would NOT recommend) you would see a normal HIT and conclude the patient might be having a posterior circulation stroke. Hope this is clear.
@@PeterJohns How can you have a normal vestibulo-ocular reflex when the peripheral sensory apparatus, the otolith in semicircular canal, sends a faulty signal? Is it that the VOR remains appropriate for the faulty signal? If the 8th CN is inflamed and sends no signal, slowed signals or incorrect signals, wouldn't this be more similar to a stuck otolith rather than a defect in central processing or motor output (eye movement) parts of the VOR? I suppose one reason could be that the head impulse isn't done in the direction of the affected semicircular canal. A related question, if you induce nystagmus with cold/warm water in the ear, will it show an abnormal (peripheral) head impulse test?
@@ravichacko Caloric testing used to be the way that VN was diagnosed, so yes. It has mainly been replaced by the manual HIT, or the vHIT, which uses video goggles. Most cases of VN involve the superior portion of the vestibular nerve. So this affects mainly the horizontal canal, leading to an abnormal HIT when the head is turned rapidly towards the affected ear. In posterior canal BPPV, the otolith in the posterior semi-circular canal does not impair the function of the horizontal canal. So the HIT in posterior canal BPPV will not be abnormal, whether you do the HIT with at rest, or if you were to the HIT during the nystagmus produced by the Dix-Hallpike test, which again, I HIGHLY RECOMMEND AGAINST DOING.
@@PeterJohns I want to be clear, I hear your recommendation not to do HIT when diagnosing BPPV, I'm trying to explore the limits of this dogma. If VN commonly involves superior vestibular nerve, which carries signals from the horizontal canal and produces an abnormal HIT: this suggests horizontal canal BPPV would have an abnormal HIT right? I've read this is 35% of BPPV, has that been your experience?
@@ravichacko I have never performed the HIT on patients with the classic positive DHT. What paper have you read with the 35% number?
What if the patient has ongoing vertigo, but no nystagmus?
First remove fixation, this video shows how. ruclips.net/video/84waYROlI4U/видео.html Then if you haven't already, screen for central features See my "big 3 of vertigo" video ruclips.net/video/00KS7Gonvq0/видео.html . If no central features, ask about previous dizzy episodes and history of migraine. This video shows how ruclips.net/video/XPIyXiv0UKg/видео.html A patient vertigo but no nystagmus and with no other worrisome features (eg fever, chest pain, confusion) and screens negative for central features and is able to walk unaided is likely safe for discharge and follow up with whomever you follow up these kind of patients with (family MD/neurology/ENT etc).
@@PeterJohns Thank you for your reply.I understand from your video that in patients who do not fulfil the AVS criteria (which requires both ongoing dizziness + nystagmus), HINTs exam should not be done because the Head Impulse test may turn out worrisome in someone completely normal, therefore causing unnecessary workup. However, I was reading up more on the test of skew, and found that a positive(worrisome) sign for test of skew is typically due to a central/brainstem issue. Therefore, the skew test is not relying on not finding vestibular neuritis to conclude stroke. It's purpose is to directly detect brainstem lesion.
In that case, would you recommend that in patients with ongoing dizziness but no nystagmus(after removing fixation), we do just the test of skew(and not the rest of HINTS) to try to pick up stroke, failing which we then move on to screen for central features and rule out worrisome features and then discharge them?
Tldr: Should we do test of skew in patients with ongoing dizziness + nystagmus, in addition to your recommendations?
Thanks!
@@ravenchua3768 I think you mean ongoing dizziness without nystagmus. And the answer is: we don't know what the value of the test of skew is in isolation. There have been no studies specifically looking at the use of HINTS in patients without nystagmus, so all bets are off.
I think really the question should be: in a patient complaining of constant dizziness but with no nystagmus, no gait disturbance, no new significant headache or neck pain, no neuro symptoms as per the central part of my Big 3 of vertigo flow chart, what is the chance that performing a test of skew will reveal abnormal vertical skew that will pick up an important finding that will make a difference in the patient's outcome? Very low in my opinion, but no studies have been done to confirm this. Thanks for the question!
@@PeterJohns Thank you !