The single best video I have found on the topic. So many doctors have failed to explain this to me all throughout medical school. Blind memorisation versus proper understanding.
Instant subscription. It seems your channel will be incredibly useful for my upcoming clinicals -- working with a vestibular specialist and trying to get down some solid foundation beforehand! Thank you!
I noticed an interesting phenomena in certain people I talk to that had this seemingly uncontrollable single eye roll when blinking + sighing over some situation. The pursuit of some explanation of that is what led me to the term Nystagmus and this is definitely the best video on that for someone who has never heard of it. Thanks.
Thank you , I was lacking a link in the chain which was the brain interpreting more activity on one side vs the other as movement in that direction hence causing the eyes to move , such simple reasoning yet missed by so many professors !!!
Thank you for your videos. Please do a video like a flow chart for BPPV. 1. DX posterior 2. Lateral geotropic vs ageo, affected ear, Bppv that had continuous nystagmus on movement, cupulothiasis? Wishing there was just a one video Bppv if this perform Epley if that perform the bbq roll, or then perform the gufoni. One time a PT moved my crystal that got into the lateral. I was stranded for the weekend because she couldn't get me back in. I watch a video and figured it was lateral when on the right side, ageo. Nystagmus pointing upward. Thought it was the right affected ear but saw a video which explained it was the left. Did the gufoni adaption and was healed in 15 min. I just wish there was a step by step DX. To figure out position in canal, affected ear and correct maneuver. There are videos but they are all chopped up. Please make the go BPPV video.
I am a physician from Thailand and I find your video very informative and easy to understand. Thank you so much, now I am more confident when treating patient who presents with vertigo. I have one question for you, from your many videos, it seems like your patients cooperate very well with the examination, which I find it really hard to do in Thailand as
I have enjoyed all your videos because as a chiropractor I see patients who are mis-diagnosed in the Emergency Room and/or only given meclazine after having head and neck MRI's and discharged. I have used the Dix Hall Pike and the Epley manuever for many years. But these videos help me know more and do more for my patients and help me learn much more that I need to know. Well done and thank you. I am digging in now to learn more and I appreciate being able to do low tech diagnostic procedures in office as well as have some tool like Epley and Gufoni to help people immediately.....Thank you for your knowledge and thorough presentations.
@@PeterJohns Thank you for being such a great resource. I had a patient come in recently with a complaint of dizziness from a local Emergency Room and his work up included MRI's of the head and neck, EKG's, and cardio blood work and the report said he had a positive Dix Hallpike. I inquired about how they performed that test and the patient said he just reported that he got dizzy when he turned his head to the left, but no procedure was done to elicit the dizziness or look for nystagmus. An example of high tech being over utilized and low tech ignored. He was actually negative for Dix Hall Pike but positive on the Supine Head Roll towards the right with up-beating nystagmus. I was better prepared to examine and treat by learning from you....At 72 I am still learning....thank you for your help.
Thank you so much for making these videos. I just went to the hospital for vertigo something i never have experienced. if i would have known this information i probably could have avoided my hospital visit. I’m sharing your videos with everyone i know because we are all getting older and will all experience Vertigo eventually. Blessed day Sir.
I glad you found this video helpful as a patient. However, this video is aimed at educating medical professionals, and not meant to replace assessment by a medical professional.
Thank you sir, never tired of this topic especially with your concise but comprehensive explanation. Please keep doing this. Also please consider doing a video on pitfalls that must be avoided/careful about and how to follow my patient to make sure I got the correct diagnosis.
Hello Dr. Johns, I am a young neurologist from Italy. I wanted to thank you for the knowledge and the very useful videos you share with everyone. I rewatch your videos often. They have changed the way I look at patients with vestibular problems! I wanted to ask you if you ever happened to perform Head impulse test to evaluate vestibular function in patients who did not have vestibular neuritis. For example in patient with neurinoma of VIII cranial nerve.
This is gold Doc, thank you very much for sharing. I have a question for you: do you find good response to antiemetic drugs like Levosulpiride can be a useful criterion for distinguishing a peripheral vertigo vs a central one? Often in our ED in Italy we administer Levosulpiride to very symptomatic patients, who are difficult to examine at first. They almost always respond well. Then we proceed screening them with a detailed neurological exam and HINTS plus test. In borderline cases or if we are not that sure, can strong and almost complete response to medication be used as a further confirmation of a more likely peripheral cause than a central one? Thanks in advance
Short answer, no. Just as good response to an antacid to someone with chest discomfort cannot be relied upon as ruling out a cardiac cause for the chest pain, neither can the response to anti-emetic treatment be used to point the diagnosis away from a central cause. I'm not sure this has been studied, but of note, Tarnutzer's papaer in the CMAJ "Does my dizzy patient have a stroke" www.cmaj.ca/content/cmaj/183/9/E571.full.pdf does not address this idea in this rather comprehensive paper.
@@PeterJohns Thank you very much. I see your point. I was reasoning on the fact that seeing a patient enter our clinic with debilitating neurovegetative symptoms and strong difficulty walking, administering them the medication and then be able to fully examine them finding complete regression of gait problems and imbalance and collecting eumetric cerebellar tests could be a valid point towards vestibular neuritis rather than cerebellar stroke. It has never happened to me, but I assume in a cerebellar stroke it would be difficult to find complete regression of gait and imbalance symptoms with a drug like Levosulpiride that acts mainly on peripheral nervous system (and only at high concentrations on central nervous system). Not to mention the fact that in vestibular neuritis we have an inflamed but well alive nervous tissue, instead in cerebellar stroke we have nervous tissue that has started do die. Anyways, this is just my speculations, not confirmed or treated in any study, as you mentioned me. HINTS plus test is clearly a very much more valuable tool to rule out a cerebellar stroke. Thank you for your answer and interest in teaching and expanding the knowledge on the subject. My respects, Luca
I am a physician from Thailand and I find your videos very informative and easy to understand. Thank you so much for making these series of video clip. I have one question for you, from your videos it seems like your patients can tolerate the examination very well, have you given them any medications prior to examination? From my own experience, it is really hard to perform the exam, even just to open their eyes to look for nystagmus. Thank you.
Thanks Dr Johns! I just have a question about the first gentleman with nystagmus, I see his eyes are brown centrally and grey peripherally. Is that indicative of another condition? Thanks again for the great video!
Thanks for the great content!! How long is the nystagmus typically present? Case question: Does the absence of nystagmus after the acute phase (more specifically, 10 days after onset of symptoms) and the presence of a positive head impulse test still point towards vestibular neuritis in the absence of any other signs or symptoms other than constant vertigo?
Typically the nystagmus is pretty easy to see in the first couple of days. Some seem to lose it fairly early after that. It's important to remove fixation in some manner (like by asking the patient to look through a piece of paper) to bring out small amplitude nystagmus that can be missed if you ask the patient to "look at my finger". Yes, the head impulse test can be abnormal for quite some time after the spontaneous or gaze evoked nystagmus is gone. But by then they shouldn't have constant vertigo.
Sr. can you make a video about treatment of vestiubular neuritis? I found myself happy but lost after the diagnosis of vestibular neuritis. Thank very much for your work
Thanks! And sure, in vestibular neuritis the most commonly affected part of the nerve is the superior branch. It supplies innervation of the horizontal canal and anterior canal. This produces the typical horizontal and torsional nystagmus. Much less commonly the inferior branch of the vestibular nerve is affected, and it supplies the posterior canal. This produces a vertical downward and torsional nystagmus. Sometimes both branches are affected. This paper explains it in more detail. www.neurology.org/doi/10.1212/wnl.0000000000003223
Many thanks for the presentation.I am little confused about nystagmus in the lady at 1:19.Her nystagmus is beating towards the left ear and you mentioned she has right sided bppv. Am I missing something?
Sir i am suffering from vestibular disorder (tinnitus, hearing loss, vertigo). This problem was started 4 years before with ear drum reputured. But in last two year it got worsen. Currently i am facing same problem of nystagmus (why because i have left year surgery tympanoplacity before 8 months but after surgery things are same. From last two months my vertigo type has changed. My eyes are shaking right to left and left to right. I cant focus on things sometimes this problem solved in few minutes or something hours. But from yesterday i m facing this problem but not solved. My mind is working perfectly but i cant walk properly. Any solution or suggestions will be highly appreciated. I am taking betahistine 16 mg from 2 years.
Could you explain why hearing loss is more a central thing than a peripheral one? Usually if there is someone with vertigo and hearing loss I would think there's a problem in the inner ear
AICA strokes (Anterior Inferior Cerebellar Artery) infarcts part of the cerebellum as well as the labyrinth. So the patient has a cerebellar stroke as well as an acute loss of balance and a loss of hearing, as the cochlea is infarcted. So they will have an abnormal HIT, but also have an acute hearing loss. Now viral labyrinthitis can also present with AVS and hearing loss. Certainly looking for new hearing loss in patients with vertigo will increase the sensitivity, and decrease the specificity of HINTS for cerebellar stroke. What the incidence is of labyrinthitis vs an AICA stroke presenting with hearing loss, vertigo and abnormal HIT is not known. I would say this: If someone had a viral URI, developed ear pain and then tinnitus and/or hearing loss and vertigo, with no concerning features or risk factors for posterior circulation stroke, I'd probably call it viral labyrinthitis and send them home. If an older person or with stroke risk factors developed a sudden onset of vertigo and hearing loss at the same time, without URI or ear pain, and had an abnormal HIT, and a new hearing loss, I would work them up for AICA stroke. Every other patient in between these two scenarios is going to depend on your resources, your tolerance for risk, and local practices.
Nystagmus has a fast component and a slow component usually. The direction of the nystagmus is defined by the faster component. Nystagmus can be vertical upwards or downward, horizontal or torsional. In vestibular neuritis it is horizontal/torsional and the fast component beats away from the affected ear.
awesome job as usual! It seems that the fast phase of the nystagmus is away from the more rapid firing neural circuit, as it attempts to correct the visual fixation?
My 2.5 yr old is undergoing whole exome screening due to congenital nystagmus. I can’t seem to learn enough about what could be the cause. MRI normal. No onh. Peripherals blonde. 20/125 ☹️
Actually, I get vertigo in all directions with vestibular neuritis depending on the head movements I perform. I also feel vertigo in my limbs (i.e. arms and legs spinning in opposite directions).
If you have vestibular neuritis, you can have dizziness brought on by any head movements. However, the direction of the nystagmus is fixed to either the left or the right.
The direction of the nystagmus which looks more like a "jerk" is the fast component. The slow component is the slower move back to the other side. Imaging falling asleep while sitting. The slow component is when you head starts to drop. The fast component is when your head is jerked back up.
The single best video I have found on the topic. So many doctors have failed to explain this to me all throughout medical school.
Blind memorisation versus proper understanding.
As a chiropractic student this video has answered so many learning gaps!
Going to my OSCE exam in medicine and this is the best video i have ever seen! Thank you for your time and help clarifying this.
Outstanding review of relevant neuroanatomy and clinical findings. Useful--like all your other videos--in my quest to be a vertigo ninja. Thank you!
I believe the term is vertigo assassin
Thank you very much Sir. Now I understand why the direction of the Nystagmus are opposite in Dix Hallpike test and in HINTS test.
First ENT rotation exam and this solidifies my studying. Thank you.
Instant subscription. It seems your channel will be incredibly useful for my upcoming clinicals -- working with a vestibular specialist and trying to get down some solid foundation beforehand! Thank you!
I noticed an interesting phenomena in certain people I talk to that had this seemingly uncontrollable single eye roll when blinking + sighing over some situation. The pursuit of some explanation of that is what led me to the term Nystagmus and this is definitely the best video on that for someone who has never heard of it. Thanks.
Your videos are singlehandedly the best resource for diagnosing and treating acute vestibular syndrome, I thank you!
Thank you for these, can never review this stuff enough
As usual, an excellent explanation and review.
What a great educational presentation. thank you so very much
Thanks PJ for sharing this infor and making this video. i hope i can help more people with this information and explanation.
God Bless
excellent video! thank you so much for making and sharing it!
Great explanation. Greets from Brazil!
Thank you for this excellent explanation!
Thank you , I was lacking a link in the chain which was the brain interpreting more activity on one side vs the other as movement in that direction hence causing the eyes to move , such simple reasoning yet missed by so many professors !!!
thank you sir. excellent explanation as always.
Diagnosed this today! Thank you for your teaching here on RUclips and when you recently came to QCH.
Excellent! Glad to hear in person teaching helps as well!
very well explained!!!
Thanks for your job
Excellent, once again
Thank you for your videos. Please do a video like a flow chart for BPPV. 1. DX posterior 2. Lateral geotropic vs ageo, affected ear, Bppv that had continuous nystagmus on movement, cupulothiasis? Wishing there was just a one video Bppv if this perform Epley if that perform the bbq roll, or then perform the gufoni. One time a PT moved my crystal that got into the lateral. I was stranded for the weekend because she couldn't get me back in. I watch a video and figured it was lateral when on the right side, ageo. Nystagmus pointing upward. Thought it was the right affected ear but saw a video which explained it was the left. Did the gufoni adaption and was healed in 15 min. I just wish there was a step by step DX. To figure out position in canal, affected ear and correct maneuver. There are videos but they are all chopped up. Please make the go BPPV video.
I am a physician from Thailand and I find your video very informative and easy to understand. Thank you so much, now I am more confident when treating patient who presents with vertigo.
I have one question for you, from your many videos, it seems like your patients cooperate very well with the examination, which I find it really hard to do in Thailand as
Educational AND soothing
UK GP trainee here - great video, thank you!
Thankyouu so much sir.... That's an amazing explanation....✨
Thank you very much, clear explanation
I have enjoyed all your videos because as a chiropractor I see patients who are mis-diagnosed in the Emergency Room and/or only given meclazine after having head and neck MRI's and discharged. I have used the Dix Hall Pike and the Epley manuever for many years. But these videos help me know more and do more for my patients and help me learn much more that I need to know. Well done and thank you. I am digging in now to learn more and I appreciate being able to do low tech diagnostic procedures in office as well as have some tool like Epley and Gufoni to help people immediately.....Thank you for your knowledge and thorough presentations.
I'm so happy to hear that these videos have helped your patients! That's why I make them, so thank you so much!
@@PeterJohns Thank you for being such a great resource. I had a patient come in recently with a complaint of dizziness from a local Emergency Room and his work up included MRI's of the head and neck, EKG's, and cardio blood work and the report said he had a positive Dix Hallpike. I inquired about how they performed that test and the patient said he just reported that he got dizzy when he turned his head to the left, but no procedure was done to elicit the dizziness or look for nystagmus. An example of high tech being over utilized and low tech ignored. He was actually negative for Dix Hall Pike but positive on the Supine Head Roll towards the right with up-beating nystagmus. I was better prepared to examine and treat by learning from you....At 72 I am still learning....thank you for your help.
Thank you so much for making these videos. I just went to the hospital for vertigo something i never have experienced. if i would have known this information i probably could have avoided my hospital visit. I’m sharing your videos with everyone i know because we are all getting older and will all experience Vertigo eventually. Blessed day Sir.
I glad you found this video helpful as a patient. However, this video is aimed at educating medical professionals, and not meant to replace assessment by a medical professional.
Probably the best explanation of this i have received. far superior to my medical school lectures. Thank you so much
Thank you sir, never tired of this topic especially with your concise but comprehensive explanation. Please keep doing this. Also please consider doing a video on pitfalls that must be avoided/careful about and how to follow my patient to make sure I got the correct diagnosis.
Thanks, All interesting topics to make videos about. I'll put them on my (already lengthy) list of videos to make.
Hello Dr. Johns,
I am a young neurologist from Italy. I wanted to thank you for the knowledge and the very useful videos you share with everyone. I rewatch your videos often. They have changed the way I look at patients with vestibular problems!
I wanted to ask you if you ever happened to perform Head impulse test to evaluate vestibular function in patients who did not have vestibular neuritis. For example in patient with neurinoma of VIII cranial nerve.
Glad you have found my videos useful. I have never seen a vestibular schwannoma in my practice as an emergency physician, so I can't help you there.
Thanks!
thanks a lot
This is gold Doc, thank you very much for sharing. I have a question for you: do you find good response to antiemetic drugs like Levosulpiride can be a useful criterion for distinguishing a peripheral vertigo vs a central one? Often in our ED in Italy we administer Levosulpiride to very symptomatic patients, who are difficult to examine at first. They almost always respond well. Then we proceed screening them with a detailed neurological exam and HINTS plus test. In borderline cases or if we are not that sure, can strong and almost complete response to medication be used as a further confirmation of a more likely peripheral cause than a central one?
Thanks in advance
Short answer, no. Just as good response to an antacid to someone with chest discomfort cannot be relied upon as ruling out a cardiac cause for the chest pain, neither can the response to anti-emetic treatment be used to point the diagnosis away from a central cause. I'm not sure this has been studied, but of note, Tarnutzer's papaer in the CMAJ "Does my dizzy patient have a stroke" www.cmaj.ca/content/cmaj/183/9/E571.full.pdf does not address this idea in this rather comprehensive paper.
@@PeterJohns Thank you very much. I see your point. I was reasoning on the fact that seeing a patient enter our clinic with debilitating neurovegetative symptoms and strong difficulty walking, administering them the medication and then be able to fully examine them finding complete regression of gait problems and imbalance and collecting eumetric cerebellar tests could be a valid point towards vestibular neuritis rather than cerebellar stroke. It has never happened to me, but I assume in a cerebellar stroke it would be difficult to find complete regression of gait and imbalance symptoms with a drug like Levosulpiride that acts mainly on peripheral nervous system (and only at high concentrations on central nervous system). Not to mention the fact that in vestibular neuritis we have an inflamed but well alive nervous tissue, instead in cerebellar stroke we have nervous tissue that has started do die.
Anyways, this is just my speculations, not confirmed or treated in any study, as you mentioned me.
HINTS plus test is clearly a very much more valuable tool to rule out a cerebellar stroke.
Thank you for your answer and interest in teaching and expanding the knowledge on the subject.
My respects,
Luca
I am a physician from Thailand and I find your videos very informative and easy to understand. Thank you so much for making these series of video clip.
I have one question for you, from your videos it seems like your patients can tolerate the examination very well, have you given them any medications prior to examination? From my own experience, it is really hard to perform the exam, even just to open their eyes to look for nystagmus.
Thank you.
Thanks for your kind words. I use medications if I need them. I'm guessing that's about 20% of BPPV, and about 50% or more of AVS.
@@PeterJohns That's very quick response, thank you so much.
Awesome
Thanks Dr Johns! I just have a question about the first gentleman with nystagmus, I see his eyes are brown centrally and grey peripherally. Is that indicative of another condition? Thanks again for the great video!
Not that I'm aware of. I thought they look quite nice!
Thanks for the great content!! How long is the nystagmus typically present?
Case question: Does the absence of nystagmus after the acute phase (more specifically, 10 days after onset of symptoms) and the presence of a positive head impulse test still point towards vestibular neuritis in the absence of any other signs or symptoms other than constant vertigo?
Typically the nystagmus is pretty easy to see in the first couple of days. Some seem to lose it fairly early after that. It's important to remove fixation in some manner (like by asking the patient to look through a piece of paper) to bring out small amplitude nystagmus that can be missed if you ask the patient to "look at my finger".
Yes, the head impulse test can be abnormal for quite some time after the spontaneous or gaze evoked nystagmus is gone. But by then they shouldn't have constant vertigo.
@@PeterJohns fantastic. Thanks so much!
@@PeterJohns how long is the typical time for symptoms to resolve?
Sr. can you make a video about treatment of vestiubular neuritis? I found myself happy but lost after the diagnosis of vestibular neuritis.
Thank very much for your work
That's a good idea.I'll put it on my list of things to make videos about.
Great video. Can you shed light on why Hypoactive lesions are mainly associated with Horizontal Nystagmus not Vertical? Thanks.
Thanks! And sure, in vestibular neuritis the most commonly affected part of the nerve is the superior branch. It supplies innervation of the horizontal canal and anterior canal. This produces the typical horizontal and torsional nystagmus. Much less commonly the inferior branch of the vestibular nerve is affected, and it supplies the posterior canal. This produces a vertical downward and torsional nystagmus. Sometimes both branches are affected. This paper explains it in more detail. www.neurology.org/doi/10.1212/wnl.0000000000003223
@@PeterJohns Thank you. :)
Many thanks for the presentation.I am little confused about nystagmus in the lady at 1:19.Her nystagmus is beating towards the left ear and you mentioned she has right sided bppv. Am I missing something?
No, it's beating upwards vertically, and also torsionally towards her right ear. There is no nystagmus beating toward her left ear.
Nice
Sir i am suffering from vestibular disorder (tinnitus, hearing loss, vertigo). This problem was started 4 years before with ear drum reputured. But in last two year it got worsen. Currently i am facing same problem of nystagmus (why because i have left year surgery tympanoplacity before 8 months but after surgery things are same. From last two months my vertigo type has changed. My eyes are shaking right to left and left to right. I cant focus on things sometimes this problem solved in few minutes or something hours. But from yesterday i m facing this problem but not solved. My mind is working perfectly but i cant walk properly. Any solution or suggestions will be highly appreciated. I am taking betahistine 16 mg from 2 years.
Could you explain why hearing loss is more a central thing than a peripheral one? Usually if there is someone with vertigo and hearing loss I would think there's a problem in the inner ear
AICA strokes (Anterior Inferior Cerebellar Artery) infarcts part of the cerebellum as well as the labyrinth. So the patient has a cerebellar stroke as well as an acute loss of balance and a loss of hearing, as the cochlea is infarcted. So they will have an abnormal HIT, but also have an acute hearing loss.
Now viral labyrinthitis can also present with AVS and hearing loss. Certainly looking for new hearing loss in patients with vertigo will increase the sensitivity, and decrease the specificity of HINTS for cerebellar stroke.
What the incidence is of labyrinthitis vs an AICA stroke presenting with hearing loss, vertigo and abnormal HIT is not known.
I would say this: If someone had a viral URI, developed ear pain and then tinnitus and/or hearing loss and vertigo, with no concerning features or risk factors for posterior circulation stroke, I'd probably call it viral labyrinthitis and send them home.
If an older person or with stroke risk factors developed a sudden onset of vertigo and hearing loss at the same time, without URI or ear pain, and had an abnormal HIT, and a new hearing loss, I would work them up for AICA stroke.
Every other patient in between these two scenarios is going to depend on your resources, your tolerance for risk, and local practices.
@@PeterJohns thank you very much!
Hopefully you see this comment today… but when you say beating away or horizontal. Are you talking about the eyes twitching one way or the other?
Nystagmus has a fast component and a slow component usually. The direction of the nystagmus is defined by the faster component. Nystagmus can be vertical upwards or downward, horizontal or torsional. In vestibular neuritis it is horizontal/torsional and the fast component beats away from the affected ear.
awesome job as usual! It seems that the fast phase of the nystagmus is away from the more rapid firing neural circuit, as it attempts to correct the visual fixation?
Yes, it tries to correct the slow phase, which was drifting off the target.
My 2.5 yr old is undergoing whole exome screening due to congenital nystagmus. I can’t seem to learn enough about what could be the cause. MRI normal. No onh. Peripherals blonde. 20/125 ☹️
Sorry, I know very little about congenital nystagmus.
Actually, I get vertigo in all directions with vestibular neuritis depending on the head movements I perform. I also feel vertigo in my limbs (i.e. arms and legs spinning in opposite directions).
If you have vestibular neuritis, you can have dizziness brought on by any head movements. However, the direction of the nystagmus is fixed to either the left or the right.
Hi 👋, what is your opinion on intratympanic injections such as steroids and stem cells for treatment?
For treatment of vestibular neuritis? I know of no studies related to that.
I dont understand how to decide fast component and slow component
The direction of the nystagmus which looks more like a "jerk" is the fast component. The slow component is the slower move back to the other side. Imaging falling asleep while sitting. The slow component is when you head starts to drop. The fast component is when your head is jerked back up.
@@PeterJohns thank you very much .. you mean corrective saccadic jerk is fast component ?
@@ChaudharySomvirDalal Of the nystagmus, yes. A saccade is the fast movement between two focal points.
Does vestibular neuritis cause heavy head?
I don't know that term.
How is this visibuler nuritis treated??? I believe I have this please help?
Thank you for making it clear regarding nystagmus