Thanks a lot! I am a general clinician in Brazil and we have nota many vídeos about vertigo in portuguese. I have seen a lot of vídeos about this theme in english, but that one was awesome! Thanks.
Thank you for your videos. I am an ENT from the Philippines and I've been occasionally going back to your channel to reeducate myself on HINTS. I've recently had an 80/F who presented with hours of vertigo accompanied by vomiting, no central features. I did the HINTS exam but I forgot that nystagmus is required. Although I thought I saw a refixation saccade, I'm glad to have stumbled upon this video addressing exactly what I may have been doing wrong - I kept constantly asking her to fixate on my nose. Thanks again! More power to your channel! You are really doing a great service and helping lots of clinicians from the world over by publishing these high - quality, straight - to - the point educational videos. :) God bless Dr. Johns :)
Based on this tiktok, I'd say yes. www.reddit.com/r/interestingasfuck/comments/10afotj/nice_demonstration_of_how_our_eyes_move/ He shows the difference between pursuits and saccades very nicely, although the technology has been refined since 1066.
Hello, Dr. Johns. I am a resident at an otorhinolaryngology service from an university hospital at Rio de Janeiro. Your channel helped me a lot during my first year of residence. I would like to thank you for your enthusiasm in sharing your experience with us. I am happy to know that even after your retirement you will continue to spread knowledge and dedicate yourself to something that pleases you so much. You inspire me.
Most cases of vestibular neuritis are affecting the superior branch of the vestibular nerve. This branch brings signals from the horizontal and anterior semi-circular canals. It's the abnormal input from the anterior canal that gives most patients with vestibular neuritis the torsional component.
previosly healthy patient admitted with 3 days of acute vestibular syndrome. nausea and vomiting x several. ate and drank badly. appetiteless. overall neurological status was unremarkable. the general condition was stable in the supine position, although a little weak. no dysatria, dysphagia, dysmetria, diplopia. HINST with unidirectional right nystagmus. neg test of skew, positive head impulses test, no auditory symptoms. the only thing that stood out was that the patient could not stand without support. The patient was assessed as vestibular neuritis, and since several days has passed, no ct brain was ordered. Admitted for observation and following the status. during the next day the general condition worsened and CT brain showed cerebellum infarction. The question is, how does the ability to walk differ between vestibular neuritis and posterior infarction? I know posterior infarct is unable to walk unaided, but so is vestibular neuritis???
Stating "overall neurological status was unremarkable" is often the first step in missing s dizzy stroke. "weak" focal weakness? "dysatria" Not a word. "HINST". It's HINTS "positive head impulses test". So was a refixation saccade, seen? And on turning the head quickly to the left or right or both sides? "no auditory symptoms" Was a bedside test of hearing performed? Sometimes a patient is so distress with their vertigo they don't notice the loss of hearing indicating an AICA stroke. "since several days has passed, no CT brain was ordered". CT scans cannot rule out a posterior circulation stroke. However, the longer the patient has been symptomatic, the higher the chance it might show something. Perhaps a CT done the day of admission would have showed something, perhaps not. Doing a CT head is not wrong in this scenario, as long as you don't think that a negative one rules out a stroke, and you try and arrange an MRI with DWI as soon as possible. And now the big finding: "patient could not stand without support". Patients with vestibular neuritis rarely are unable to stand without support. And patients with vestibular neuritis will be starting to cover after 2 days and should be able to stand and walk unaided. And patient with posterior circulation strokes can sometimes walk without support. See the video of this patient with a posterior circulation stroke. ruclips.net/video/MgzhbsxzBdA/видео.html So it's not a binary finding. That is, it's not "can't walk unaided = central" and "can walk unaided = vestibular neuritis". It's more "can't walk unaided= rule out central" not matter what the HINTS exam shows(but it still could be a bad vestibular neuritis in the first day or two) and "can walk unaided = more likely to be vestibular neuritis" but screen for all central features, and apply the HINTS exam including bedside test of hearing. before making the diagnosis.
Both women; Do you see a prevalence of vertigo in women who may be in peri or full menopause? I had recurring BPPV that disappeared once I started menopausal hormone therapy. I certainly don't miss it!
Thank you for explaining the paper trick, this is super helpful
absolutely!
Thanks a lot! I am a general clinician in Brazil and we have nota many vídeos about vertigo in portuguese. I have seen a lot of vídeos about this theme in english, but that one was awesome! Thanks.
Glad you liked them. I have a lot of other ones you might want to look at. www.youtube.com/@PeterJohns/videos
Thank you for your videos. I am an ENT from the Philippines and I've been occasionally going back to your channel to reeducate myself on HINTS. I've recently had an 80/F who presented with hours of vertigo accompanied by vomiting, no central features. I did the HINTS exam but I forgot that nystagmus is required. Although I thought I saw a refixation saccade, I'm glad to have stumbled upon this video addressing exactly what I may have been doing wrong - I kept constantly asking her to fixate on my nose. Thanks again! More power to your channel! You are really doing a great service and helping lots of clinicians from the world over by publishing these high - quality, straight - to - the point educational videos. :) God bless Dr. Johns :)
One again a great video! Thank you for continuing teaching even after you retire from clinical practice.
I found your videos extremely helpful. Thank you for continuing to educate us even after you retire!
Thank you for this simple but very helpful tip. Great video!
Your videos have helped me in my medical practice. Thanks!
Great to hear!
Hi dr johns, otolaryngologist here 👋, sir, I am on a mission to make you famous in Egypt 🤝😀, many thanks for your effort ❤🌷
Your videos are appreciated. Use them for the emergency neurology department
FASCINATING... I wondered where you were going with the blank piece of paper. Thanks.
Thanks Peter, very informative and helpful videos for all things vestibular.
Very educational and informative. Really helps with ENT exam preparation
❤❤❤ "As fabulous as always! Love your presentation. Many thanks.❤❤❤
would an arrow protruding from the eye, aid in detection of subtle nystagmus? Sadly the Bayeux Tapestry doesn't specify.
Based on this tiktok, I'd say yes.
www.reddit.com/r/interestingasfuck/comments/10afotj/nice_demonstration_of_how_our_eyes_move/
He shows the difference between pursuits and saccades very nicely, although the technology has been refined since 1066.
We wating for this good Guide video. Thank you.
Thank you!
That was awesome!
Thank you so much for this practical tip Sir
Excellent exposition Where were you when I was beset with talentless teachers ?
Thanks for video, it was very useful.
Amazing!!
Thanks!!!
This some good stuff
Hello, Dr. Johns. I am a resident at an otorhinolaryngology service from an university hospital at Rio de Janeiro. Your channel helped me a lot during my first year of residence. I would like to thank you for your enthusiasm in sharing your experience with us. I am happy to know that even after your retirement you will continue to spread knowledge and dedicate yourself to something that pleases you so much. You inspire me.
Thank you so much. It means a lot to me. If you make vertigo an area you care about in your career, it will be the greatest thanks I can get.
Why is there a torsional component to this beat?
Most cases of vestibular neuritis are affecting the superior branch of the vestibular nerve. This branch brings signals from the horizontal and anterior semi-circular canals. It's the abnormal input from the anterior canal that gives most patients with vestibular neuritis the torsional component.
previosly healthy patient admitted with 3 days of acute vestibular syndrome. nausea and vomiting x several. ate and drank badly. appetiteless. overall neurological status was unremarkable. the general condition was stable in the supine position, although a little weak. no dysatria, dysphagia, dysmetria, diplopia. HINST with unidirectional right nystagmus. neg test of skew, positive head impulses test, no auditory symptoms. the only thing that stood out was that the patient could not stand without support. The patient was assessed as vestibular neuritis, and since several days has passed, no ct brain was ordered. Admitted for observation and following the status. during the next day the general condition worsened and CT brain showed cerebellum infarction. The question is, how does the ability to walk differ between vestibular neuritis and posterior infarction? I know posterior infarct is unable to walk unaided, but so is vestibular neuritis???
Stating "overall neurological status was unremarkable" is often the first step in missing s dizzy stroke.
"weak" focal weakness?
"dysatria" Not a word.
"HINST". It's HINTS
"positive head impulses test". So was a refixation saccade, seen? And on turning the head quickly to the left or right or both sides?
"no auditory symptoms" Was a bedside test of hearing performed? Sometimes a patient is so distress with their vertigo they don't notice the loss of hearing indicating an AICA stroke.
"since several days has passed, no CT brain was ordered". CT scans cannot rule out a posterior circulation stroke. However, the longer the patient has been symptomatic, the higher the chance it might show something. Perhaps a CT done the day of admission would have showed something, perhaps not. Doing a CT head is not wrong in this scenario, as long as you don't think that a negative one rules out a stroke, and you try and arrange an MRI with DWI as soon as possible.
And now the big finding: "patient could not stand without support". Patients with vestibular neuritis rarely are unable to stand without support. And patients with vestibular neuritis will be starting to cover after 2 days and should be able to stand and walk unaided. And patient with posterior circulation strokes can sometimes walk without support. See the video of this patient with a posterior circulation stroke.
ruclips.net/video/MgzhbsxzBdA/видео.html
So it's not a binary finding. That is, it's not "can't walk unaided = central" and "can walk unaided = vestibular neuritis".
It's more "can't walk unaided= rule out central" not matter what the HINTS exam shows(but it still could be a bad vestibular neuritis in the first day or two)
and "can walk unaided = more likely to be vestibular neuritis" but screen for all central features, and apply the HINTS exam including bedside test of hearing. before making the diagnosis.
neat
How can I submit for CME?
Ha, not from this channel. This is all free open access medical education.
How do we differentiate from end gaze nystagmus?
Watch this video. Happy to answer any question you have afterwards. ruclips.net/video/4KBlzEHk-N8/видео.html
@@PeterJohns cleared it up beautifully!
Congratulations on retirement!
Thanks! So far, not working is more fun than working. And more time for teaching vertigo, which is not work to me!
You poor girl
Thank you so much! It's so helpful
Congratulations on retirement!
Both women; Do you see a prevalence of vertigo in women who may be in peri or full menopause? I had recurring BPPV that disappeared once I started menopausal hormone therapy. I certainly don't miss it!
Vestibular migraine is very common in perimenopausal women, and often seems very positional. I have a video on that.
Thx very much! from Chile