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Amazing video, thank you!

very very helpful for my ENT case presentation this week! thank you doctor

Very nice and that makes significant change in my daily clinical practice about dizzy patients. Thanks so much.

Have you heard of Aimovig causing a new symptom of vertigo? Or if it does?

What if you have congenital nystagmus? 😭

This was very helpful and the kid made it cute. One thing kind of hung us up--you say 90 degrees and my husband and I are both thinking, "Isn't that 180 degrees?" Is it us?

Very usefull,thanks alot

thanks alot

Does this manoeuvre need to be repeated or should it work first time? Thanks 😊

Thank you Dr. Johns, this is a very helpful content

I really enjoy your vertigo videos and infact I recommend every doctor to watch your videos on this extremely topic. Just one thing that I think is not right: I note that You are advocating impulsing the head from right or left lateral to midline instead of jerking it laterally from midline primary position. This must be your own or someone else’s modification, because I have not read this method of Head Inpulse in any neuro text including Adam and Victor’s and Blumefeld’s Neuroanatomy through Clinical cases. Professor Haymalgayi who described this test has also not described it and he is the guy here in Australia who does all the advances testing in spinning chair and much more when no one can figure out what is making the patient dizzy. And I dont conceive how test ever will or ever could be validated the way it is being suggested here. There are simple and very obvious anatomical and physiological reasons why it cant be validated this way: the premise and foundation for the head impulse testing is the anatomical and physiological fact that in primary position the gaze centring mechanisms on right and left are firing equally which is necessary to keep the gaze in primary position. This ‘centring tendency’ is the default position and action of the brain mechanisms that mediate it. Lateral head position with fixing the eye on a point straight ahead is a deviation and a departure from the default state. Once you move the head to right or left those impulses have changed in their amplitude and firing frequencies to keep the eyes fixated straight forward. Moving the head from right or left lateral to the midline is not the same as jerking the head to right or left lateral because neuronal impulses have to change to make adjustments. When you move the head away from that specifically defined primary gaze position, then you have changed the afferent impulses firing rates and amplitudes of the brain mechanisms and impulses that mediate the VOR hence and keep the eyes centred, thus altering the validity of the test. So we can not just swap the test around(even if it is with the noble intentions of making it more comfortable for the patient). The primary position for VOR and semicricular canals is the primary gaze position which is head horizontal in neutral position and looking straight forward as in anatomical postion and the eyes gazing straight forward. But I look forward to be corrected and educated by such a learned and highly esteemed colleague like yourself. If you have any clinical references I look forward to reading them and the primary references they mention. Regards A 26th year medical student.

19:20 are you saying that if nystagmus is left beating then in vestibular neuritis head impulse will also be when head is impulses to the left. That is opposite to what you have been saying earlier in this video (and many other videos). If his left vestibular nerve is affected, his HI test would have catchup saccade when his head is turned impulsed to the RIGHT, not left side. Or did misunderstood something? Would appreciate if you can clarify please. Thanks.

Awesome video!!! But I want to know how to diference the central problem when the pacient have acute vertigo but not nystagmus. Does anyone have any material?

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???

Hi Dr. Johns, I'm a novice medical student, so please forgive me for the very basic question, but I'm wondering how we should interpret gaze-evoked nystagmus (similar to what you mention at around 29 minute mark of the video) in a patient with continuous vertigo, but no spontaneous nystagmus (I.e. when at rest looking straight ahead). Should we also not do a HINTS exam on these patients? Based on the phrasing that we should only be doing HINTS exams on pts with acute vestibular syndrome and spontaneous nystagmus, my assumption is that the answer is NO, but just want to clarify. Thank you.

Thank you so much sir, that was very crisp to the point and informative at the same time

الف رحمة على روح والديك

My eyes roll to back of my head. Had it since 7 years old now I’m 64.

Very good video...precise and easy to understand

Can you please expand on those with constant dizziness without any nystagmus? What testing do you do in office?

Deeply useful, thanks.

Brilliant.

Dr. Johns, thank you for the video. I am undergoing my emergency medicine postings and attending my ENT (as we refer to the subject of Otolaryngology in India) classes at the same time, this video quite comprehensively integrated the concepts for me. Grateful to you for sharing your knowledge and experience with the young buds.

This is a great video. Simple, to the point and with EXCELLENT patient videos.

WoW. Looking at your videos list...Its not hard to see what you are obsessed with ..😊. Cheers.

BEST EVER NOW APPROACG FOR VERTIGO SO CLEAR AS BEFORE WAS CONSUDED LITTLE BIT. THANK YOU.

I see a lot of comments on good video but no mention as to the successful treatment of vm as many of us have been on all kinds of meds with no relief

Beautifully explained. Thank you

perfect! thx very much

Thx very much! from Chile

great explanation. Much appreciated sir!

Thank you this helps I get vertigo all the time

Thanks!!!

Slappin' info, my beautiful medical guy! Keep up the good work here on youtube. Most vertigo videos are pretty superficial and you can't really apply the skills at all afterwards because the information is too vague/inconsistent. Ex: central vertigo ALWAYS has a slow onset, peripheral ALWAYS has a sudden onset. How about stroke? So many times strokes are overlooked, people don't even look for them.

Thanks for your videos. I would like to suggest that the HIT is useful to do on a patient without gaze nystagmus to assess for unilateral hypofunction. This is not in context of the ED environment where one might be ruling in or out life-threatening etiology, but is helpful in a physical therapy environment to create an exercise program to strengthen the overall system and decrease falls risk. (Herdman, 2011)

Finally the full explaintion

I'm at a crossroads. The first ENT diagnosed me with VM and the 2nd tentatively with Autoimmune inner ear disease based on very slight hearing improvement on prednisone. (But wasnt convincing enough) The symptoms were: occasional episodes of intense vertigo with loud tinnitus and muffled hearing lasting under 10 mins usually. (Usually brought on by alcohol/stress/caffeine I find) permanent high frequency hearing loss from 2K+ hz (I have a family history of Vestibular migraine symptoms and high frequency hear loss from a young age) Other episodes were classic migraine aura and headache and sometimes aura but no headache and other times intense headache but no aura. Most days are slight dizziness/unsteady on feet and slight hissing in ears. So I'm planning on consulting a neurologist to try some migraine prevention medication in hope I can arrive at a solution

👌👌👌

In high school, I would have headaches preceded by visual auras (like TV snow). I was 35 and pregnant when I the vertigo attacks started which lasted days to weeks. I don’t remember having any headaches. an ENT doc diagnosed me with Ménière’s disease and treated me using Lasix, Topamax, Balance Therapy, and taught me the Epley maneuver. None of it worked. I didn’t have: tinnitus, hearing loss, TIAs/CVAs, vestibular neuritis, or BPPV. Both my CT and MRI were unremarkable, I was an unlucky enigma. The vertigo would return but was manageable, and resulted in a weekend quick care and steroid injection. It stopped being manageable when it went on for weeks then months at a time. I couldn’t drive and I couldn’t work (I was a Flight Paramedic working on a helicopter for 23 years). I went to a neurologist, and he redid all my testing. He was skeptical about the migraine/vertigo relationship as he told me I should have a history of migraines. What I didn’t know was I had a history but didn’t recognize them as migraines. I thought they were stress headaches. He went over my recent MRI showing almost white out areas, or “hyperdensities” indicating areas of migraine origin. I kept a “ migraine diary “, so now I can recognize symptoms 1-2 days before vertigo hits. He tried standard treatments that didn’t work. Now, I take Topamax, Valium (calms the vertigo so I can sleep), Zofran, Nurtec (for a breakout med), Botox (every 12 wks) and Emgality (self-administering injection) for prevention. The Emgality was a game changer for me. I went from 2-3wks/month of vertigo to none or 1wk/month.

I've been having these types of migraines but I've also noticed the aura's are very different from the other migraines I may get. They are darker, more lose of the visual field and black spots would appear. Anyone else experiencing this?

best video ever on nystagmus..thanks

Grateful 🙏🏻

That is very clear " bedside teaching", thank you.

Great! Tkanks

Hi Dr.Johns, I performed 2 epley manuevers on a 76 yo pt after he had a fall and became dizzy at home when getting out of bed. He stated that his vertigo lasted for about 8 sec. I performed the DHT and sure enough he was positive. Thanks you for all of your great info and patient examples.

Someone asked: "Am I to understand that practically all stroke patients presenting with vertigo have spontaneous nystagmus? What do I do with patients who report persistent vertiginous symptoms (i.e. acute vestibular syndrome) but zero nystagmus and no other neurological findings (e.g. ataxia, diplopia)? Consider it as stroke if the HIT is normal? " For the answer, watch this video at this time stamp. ruclips.net/video/MgzhbsxzBdA/видео.html

Amazing!!

Hi peter, i've had difficulties with one patient. Typical BPPV history, dix hallpike negative on right side, positive on left side with typical posterior canal bppv nystagmus. Treated with epley maneuver. Tested again after 15min, dix hallpike negative. But when she was about to leave it happened again but different and more intense, mostly when looking up or down. I retested with dix hallpike still negative. On the supine roll test : nothing on the right but on the left i had rotatory nystagmus almost like a posterior canal with maybe (big maybe) geotropic horizontal component. I tried the gufoni maneuver for left ear geotropic bppv without success. It feels like it's a conversion but the nystagmus is really rotatory and not horizontal. Have you encoutered same situation? Do you think it's still posterior bppv?

Thank you so much! Your explanation is genius!

Hello Peter Johns.. about 5 years ago I started a spell of panic and what an urgent care center quoted me as having a “double ear infection”. I later went to an ENT who’s impression was this. That most of my dizziness was caused by anxiety - and that maybe the urgent care even misdiagnosed me. He sent me for a VNG test to later check and make sure. He recommended me now almost 4 years ago to get an MRI done with contrast as my nystagmus was borderline unusual during the VNG (by 1%) but I found other professionals use a test of 25% rather than 20%. I am wondering if it is your advice that this is leaning towards a real central issue, or something more like dissociative disorder caused by anxiety. I do have double vision corrected by spheres which helps some, but it’s a general sense of things maybe ever so slightly moving in my environment and like a fog over my head. It has been 5 years and symptoms have not gotten much worse or better except in times of panic they are exacerbated. My movement has never been impaired at all in the slightest or motor function and my facial features are fine. Here is his impression on my first visit. Then a response to his recommendation for an MRI following the ever so slightly “abnormal” nystagmus from the VNG test. Having panic disorder, I don’t believe I can sit in an MRI machine, and that’s why I have been avoiding this for 4 years now. If you could give me some advice or say maybe what the standard is or if you think this is a central problem that I can get diagnosed some other way than an MRI it would be greatly appreciated. Initial consultation description and impression from ENT: History of Present Illness (Denise Biggs; 1/22/2020 3:27 PM) The patient is a 25 year old male with ear complaints. The patient is here for a consultation. The patient's chief complaint is dizziness. The history today is reported by the patient. and began 2 year(s) ago. and include middle ear fluid. Note for "Ear complaints": . This is a 25-year-old gentleman who has an 11 month history of what he describes as dizziness. No true spinning vertigo, just more a feeling of unsteadiness. The patient says he has a history of anxiety and is very anxious today in the office. He has no history of ear surgery. He says this all began after an infection where he was seen at an after hours clinic. He has never had any hearing loss or tinnitus. Even when he had the infection, he does not remember his hearing being down. He is not having trouble with drainage. He has never had ear surgery. He denies pain, tinnitus or hearing loss. When I closely questioned him about the dizzy spells, they are not vertiginous or spinning, just more a feeling of lightheadedness where he says he feels as if he is floating. Impression: He has normal hearing and type A tympanograms. The patient is clearly very anxious. I had a long discussion with him about the possibility of this being an anxiety disorder. He related to me that he has been treating the anxiety with ethanol, and I strongly counseled him and I recommended he discuss that with his family doctor. He has no evidence of hearing loss. I do not think this is inner ear but I would like to evaluate him with an ENG. Pending review of the ENG, I would recommend he return to see his family doctor for evaluation and treatment of possible anxiety disorder, which could be contributing to the dizziness. Messages later after VNG discussing results: Just to clarify the Peripheral vertigo of the left ear is just a general diagnosis in your chart that was used during an apt not the final diagnosis and that is why it shows on your chart on the website. The Dix-Hallpike test done during the VNG tests for peripheral vertigo was negative for both ears. For the vestibular function any difference between the ears of below 20% is considered normal. Your difference was 21%. > From: Kendall, Blake J. > To: Semler, Jennifer > Sent: 2/25/2020 9:03 AM > With ENG only slightly abnormal, MRI is to check brain as well as hearing/balance nerves. VNG tests both central and peripheral. MRI is next step. DW