Why are we still confused about how to use the HINTS exam?

In this video I cover:
1. How and why to screen for central features in vertigo patients
2. What you need to see in order to discharge someone with a diagnosis of vestibular neuritis
3. Why you shouldn't do the HINTS exam on patients without nystagmus
4. What to do with those patients with constant dizzy and no nystagmus

[MrMustybooks]

Excellent video. Primary care doctor in UK. Is a struggle to find any clear guidance on no nystagmus with persistent dizziness now i understand why. So that was really useful alongside when not to use HINTS and why. Thank you!

[rachelshemtov]

Thanks so much for this. I rewatch it every few months. I work on a small Ed without easy access to MRI and it's clinical gold.

[Tagmose]

Hi Peter !

As always clearly and thoroughly explained with logical arguments! Where do I sign the petition for getting you, Drs Edlow, Newman-Toker and Kattah in the same room and discuss the 2% that you guys disagree about !?

Small comments / questions (it’s a bit long - sorry. And I have no expectation of getting an answer)
- 1) To HINTS plus or not : To my knowledge there’s no studies (and probably won’t be any) of the + / hearing loss part in HINTS+. Let’s say you have a patient testing negative central features, and the HINTS test suggest vestibular neuritis but the patient also has hearing loss (ruling in for HINTS+). I guess there’s no safe way other than an MRI to differentiate the AICA stroke from Labyrinthitis (in my experience they tend to have elevated inflammation makers as well, but probably that is not a specific enough finding to rule out the AICA)?
- 2) the “AVS+nystagmus”-like presentation in some BPPV patients: I think some of the confusion with application of HINTS lies in not knowing the data . But I think some of it may be as simple as interpreting what the patient is saying . “Constant dizzyness” is something I hear from some monosymptomatic dizzy patients with a history suggesting BPPV (even though it may be 10-20% of max dizzyness for the patient as opposed to the true “dizzy at baseline” patient with AVS who is maybe at 90-100% of max dizzyness when lying still). Now some of these BPPV patients may have some residual nystagmus if you are not careful in your instructions to them to not move their head for a couple of minutes (especially if they have cupolithiasis and not canalithiasis). So in my experience (which of course may be wrong) some dizzy patients with BPPV will have an “AVS + nystagmus”-like presentation. And I suggest in these cases to my colleagues that if the history and exam in all other aspects suggest BPPV, then I’d try to do the dix hallpike/ supine head roll to see if you get a clearly positive test.
- 4) Exclusion criterias for HINTS and false positive AIS patients: The patients that are NOT too good walkers at baseline (frail / elderly etc ) or patients who are drunk, would probably be false positive on the approach we advocate for because of their baseline nystagmus and / or gate instability and perhaps in these patients the tests could be used by a case by case basis, but one should be careful of ruling out central causes by bedside manoeuvres alone
- 5) HINTS with enucleated eyes with re-attached muscles to the prosthetics: we came across a patient with monosymptomatic constant dizzyness, but with bilateral eye enucleation and the gait was per usual? We went for an MRI on that patient that was normal, but curious if you had done it differently

All the best
Peter

[sithulin]

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

[AdilRashid-vu]

Hi peter; I re read GRACE 3 after watching your video, which is by the way very neat;
In their paper, authors have pecially mentioned NOT to use HINTS in the patient WITHOUT nystagmus, and they even follow that statement with an example (a patient with dizziness due to anemia) to help clarify their point;

[nipatel]

Thank you Peter! Practicing clinicians sometimes have so many conflicting pieces of information in our head that beating the information into us is needed to shake the bad information loose. I'll find something other than the HINTS exam to do if a patient does not have persistent dizziness and nystagmus at rest. Like getting a cup of coffee...to give me more time to think.

[AlexanderRoux]

Emerg trainee here
Thanks
Loud and clear

[AmyWilliams]

I took my friend to the ER 12 days ago becaise she woke up in the middle of the night extremely dizzy, with naseau and vommitting. Any eye or head movement made her vomit. She also had pain in her neck. She has a history of migraines and a history of neck pain on and off, but has never had dizziness like this. She had to use a walker because she was so dizzy. The ER dr did not check for nystagmus. He did a CT to rule out a stroke. The CT appeared normal. So he said she either had a specific type of migraine or she had an inner ear problem and needed to see an ENT, or she dislodged the crystals in her inner ear and needed the Eply Maneuver, but he said he doesnt do it. He told her to follow up with her PCP and gave her anti nausea meds. Finally after suffering with ongoing dizziness for 10 more days, her PCP finally saw her. They said they agree she probably needs the Eply, but they also dont do it. They described to her how to do it and told her to do it herself at home twice a day. She tried to do it to herself, but probably didnt do it correctly because she still has dizziness. Now That I saw your video and know about nystagmus, I could check her to see if she has that at rest. But since it has now been over 12 days, Would there be any point? I am assuming a migraine or stroke would not continue to cause dizziness for this long? Her dizziness improved several days after leaving the ER, and then has continued at the same level since then.

[ruthlarson]

Thank you for this in-depth information. Question…Why was the Romberg done in the 2nd pt? I am thinking that the examiner is testing for balance, but romberg isn’t a cerebellar test…was it done as a vestibular evaluation ….what was the yield in this scenario?

[deeash]

@peter
Hi Dr Peter, Your videos are really informative and have been of real help for me.. So firstly thank you .

Wanted to know, about pediatric BPPV.. I had a 11 yr old boy, with symptoms of rotatory giddiness, 2 episodes over a span of 1 month, . triggered by lying on the bed, no h/o headaches... On dix hallpike, he experienced giddiness on right side.. but there was no nystagmus . Do i treat it as BPPV.... ? Or.. is there something else that need to consider ..

[harryzhao]

Hi Dr. Peter, I am a GP from Beijing, China. Most Chinese doctors cannot watch your fantastic vertigo videos because of network limitations
and language barriers. Can I forward your videos to one of the Chinese video websites (bilibili) and put the Chinese subtitle? Thank you, Peter!!!

[chasingmoose]

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)

[yafitcohen-shwartz]

Excellent videos. My name is Yafit and I am a physical therapist from Israel.
I mainly treat people who suffer from acute and chronic dizziness. Always enjoy learning from your videos!
Thank you very much - I would be happy to host you in Israel (on calmer days :)

[VertifyMed]

Dear Dr. Johns.
Great and professional video!
Hope you saw what we do. Could be useful to record eyes.

[wookie]

I'm curious if there are any resources you'd recommend around diplopia without other central features in patients with nystagmus and dizziness? If a patient with rest nystagmus and otherwise appropriate for HINTS+ has a binocular diplopia at ~30-35 degrees gaze but no other central features and without an obvious gaze palsy, should this patient go directly to imaging? With a gaze palsy, the interpretation is much easier anatomically, but I find the interpretation of diplopia without gaze palsy somewhat confusing.

[StefanEberspaecher]

Amazing! If that's not clear I don't know what is. Thank you.

[braoramesh]

Does the nystagmus at rest ( while looking straight ahead) and the nystagmus only on gaze deviation either left or right carry the same significance while subjecting them to HINTS examination? Thank you very much for the educative video.

[thewhiteapparation]

Thank you. This is the best information on HINTS I have ever found. Amazing. What are your thoughts on other dx of continuous/constant vertigo e.g. PPPD, mal de debarquement etc. Are HINTS useful in these cases? They frequently do not have spontaneous nystagmus, so I guess I already know what you'd say :D

[haemojz]

Wouldn't an AICA stroke typically cause bi-directional nystagmus or a postiive test of skew? I would think findings suggesting peripheral + hearing loss would point towards labyrinthitis more so than an AICA stroke. (I do however understand that HINT is originally designed to differentiate AVS vs central cause, just find the recommendation a bit strange)

[maxgiesken]

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.