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So labyrinthitis is where the same dizziness/vertigo (worse with head movement) nystagmus, nausea/vomiting and difficulty walking is present, but also there is hearing loss and/or tinnitus. The real question is: How do you differentiate labyrinthitis from an AICA stroke? And here is my answer on that. Labyrinthitis is rarer than vestibular neuritis. I'd say I see 20 cases of vestibular neuritis for every labyrinthitis. In labyrinthitis, you have hearing loss or tinnitus, while in vestibular neuritis you do not. People often mistakenly refer to vestibular neuritis as labyrinthitis. What the incidence is of labyrinthitis vs an AICA stroke presenting with hearing loss, vertigo and abnormal HIT is not known. If someone had a viral URI, developed ear pain and then tinnitus or hearing loss and vertigo, with no concerning features or risk factors for posterior circulation stroke, and I saw an abnormal HIT, as well as unidirectional nystagmus and no skew, I'd probably call it viral labyrinthitis and send them home. Unless of course they had other central features. 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 Thanks good explanation

That is very wonderful to hear. The highest kind of compliment is to hear that you have learned to help people. Thank you!

Ha! I didn't know it was rated!

Haven't seen a lot of that myself.

Yes, oddly both videos came from down under.

@@PeterJohnsI work in an Australian ED and I’m constantly amazed by the number of dizzy patients referred for CT and further neuro work up /admission by clueless ED docs who can’t do a proper evaluation of the dizzy patient. You should visit down under and do some teaching 😂

Sorry to hear you practice in such a non-evidence based environment. What kind of nystagmus do you see on both left and right Dix-Hallpike test? Are you familiar with horizontal canal BPPV? czcams.com/video/VRjRTnIw9YE/video.html Vestibular neuritis will almost always have nystagmus at rest, while BPPV will almost never it. Look carefully for nystagmus as I show in this video. czcams.com/video/eGcUTfeHvZg/video.html Doing the DHT on patients with vestibular neuritis may make a patient feel more dizzy and make a non-specific worsening or bringing out some horizontal nystagmus.

You will learn a ton on Dr. Johns' channel. Another resource on CZcams that is more PT-centric (hope it's ok I plug this channel here) is Balancing Act Resources : www.youtube.com/@BalancingActResources If you have access to MedBridge, I highly suggest the courses by Jeff Walter, DPT (he has videos on YT also, I believe, but the Medbridge courses give you CE credit)

TY! I will definitely continue watching your videos and will check out that video series by the PT also. The medbridge series is on my list too. I totally need further education but also need to get a better grasp on the ordering the different assessments that I do.

You know, light cupula is not something I have a good grasp on. Someone with experience diagnosing it will have to make a video.

1. Yes, vertical nystagmus at rest is almost always a central cause (very rarely, inferior vestibular neuritis can do it). CT head or CT angio is has very poor sensitivity for posterior circulation strokes, which are the most common central causes of vertigo. So a negative CT head by no means should be reassuring if the patient has vertical nystagmus at rest. The gold standard is a delayed MRI. 2. Many patients with BPPV will complain of a lesser continuous dizziness and have no nystagmus at rest. Patients without nystagmus at rest are OK to do the Dix-Hallpike or supine roll test on, and if the nystagmus is consistent with either posterior or horizontal canal BPPV, then the diagnosis is made. Patients who complain of dizziness and have no resting nystagmus but have a new objective difficulty walking are at high risk of stroke. But it's important to look carefully for nystagmus at rest in patient with complaints of persistent dizziness. Sometimes you only see it if you remove fixation, which can be easily accomplished with a blank piece of paper. czcams.com/video/eGcUTfeHvZg/video.html

Haha! I remember showing a classic positive DHT to an older ED doc and him going "ooooo....vertical.... that's bad!" I also heard a medical student say that she saw a case of BPPV with another doc and when the nystagmus was vertical, the patient had to have a CT head "just to be sure". Ouch!

@@PeterJohns my favorite is when the learner presents a patient on whom they have (proudly) performed both a DHT and a HINTS, yikes.

@@olympiashorts I heard a neurologist was referred a patient and the referring team said the HINTS exam was "negative". The neurologist asked "just to be clear, what did the head impulse test show?" The answer: "It wasn't done, so it was negative". Doh!

I recently consulted a patient who was admitted to neurology with acute vestibular syndrome with spontaneous left-beating horizontal nystagmus, positive HIT to the right, no skew, no other pathologies because „repetitive Semont manever wasn’t effective”.

@@michamachaa8775 I've seen a woman admitted to neurology for vertigo, had an MRI, and sent home. But was still dizzy moving around! I saw her and diagnosed her with horizontal canal BPPV. Cured her, sent her home.

I only use vestibular sedatives if the patient can't tolerate the Dix-Hallpike or Epley maneuver. I'd say I have to use them in about 20% of cases of BPPV. I don't believe they will affect the diagnostic accuracy or effectiveness of the Dix-Hallpike test or the Epley maneuver.

@@PeterJohns thanks... Greatly appreciate your input

Interesting! So they had end gaze nystagmus?

There is no doubt in my mind that if someone were to document the findings that I outlined in this video, that it would be very strong evidence that the examiner did a very through and thoughtful evaluation. And really, writing a good medico-legal chart is is simply performing a good evaluation and documenting that you did so. I am not aware of any published papers that looked at the ability of any approach to vertigo with regards to preventing a lawsuit.

Thanks. I am no longer in clinical practice. Still active in vertigo education for medical professionals though.

Thank you!

Yes, but i prefer the term "vertical upward and torsional towards the downward ear". This emphasizes that vertical upward nystagmus during the Dix-Hallpike test is a normal thing to see, and not indicative of a central cause. Many unwarranted and useless CT scans of the head have been done on patients with BPPV because the examiner thought that all vertical nystagmus is worrisome for a central cause.

Glasses laka ke rakhu

I've seen studies show that vestibular sedatives can decrease the amplitude of the nystagmus, but I've never seen a study showing that it would completely suppress it. I've remove fixation with a piece of paper if I didn't see nystagmus at rest.

Glad to hear you're feeling better. Mostly people can probably get away with one minute in each position, but I don't think it hurts to do 2 minutes.

The reason why the head impulse test (HIT) is horizontal is because almost all patients with vestibular neuritis have horizontal nystagmus. Only around 2% of patients with VN will have it affect the inferior portion of the vestibular nerve only. These patients with inferior vestibular neuritis will have vertical nystagmus which is beating away from the forehead. Someone trained in how to use the head impulse test in that direction would come in handy. I am not that person. I'm not sure I can give you a good answer about the second question. I am a retired emergency physician with a keen interest in teaching others how to evaluate vertigo, but I am not a an expert in all things related to vertigo.

@@PeterJohns doc, your answer was brilliant as always. Just one more question, I was curious about the vor with eyes closed and after doing researches it says that it works in total darkness and with eyes closed. In my experience, I noticed that when moving the head to the left with eyes closed, after fixating on a target, my eyes doesn’t move behind my eyelids at all but move right before opening the eyelids, differently from the right side that the eyes moves behind the eyelids. Does the vor actually work with eyes closed, and is it possible/ does it means something to have an asymmetric vor with eyes closed?

@@guilhermenunes8460 No idea. I've never tested the VOR with the eyes closed.