Vertigo Maneuvers: Performing The Hints Exam

Figure out the cause of your patient’s vertigo and whether it’s life-threatening. In this video, you’ll learn how to perform and interpret the three elements of the HINTS exam to differentiate between central vertigo and peripheral causes.

Most advice on vertigo is daft because it just looks at masking or hiding the problem. Our first suggestion is always going to be learn to deal with the root cause and properly overcome vertigo and dizziness.

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the hints exam helps to differentiate central and potentially life threatening causes of vertigo from vestibular neuritis which is benign it’s comprised of three tests first the head impulse test second the tests of skew and third the nystagmus assessment a chai tea stands for head impulse test this test uses the vestibulo ocular reflex to predict whether the vertigo is peripheral or central in patients with ongoing constant vertigo and nystagmus this reflex allows your eyes to stay focused on an object despite head movement go ahead try this now shake your head quickly from left to right up and down and look at the center of the screen your eyes will be able to read the words without any trouble as you can imagine this reflex came in very handy for a caveman running away from a saber toothed tiger the caveman would surely not survive if he couldn’t focus on the direction he was going while bouncing up and down running through the jungle this test is only performed in a patient who has active and persistent vertigo and nystagmus you’re trying to see if the eighth cranial nerve the vestibulocochlear nerve has been affected by a virus to perform this test ask the patient to stare at your nose hold their head in your hands and move the head thirty degrees to the side and rapidly bring it to the midline while staring at their eyes this method is preferred because it will avoid potentially over rotating the neck and causing spine or artery damage if the vestibular ocular reflex is affected by a virus the eyes will keep moving in the direction of movement and then quickly jerk back to looking at your eyes this is called a corrective saccade and will only happen in one direction so be sure to test both sides if there’s a normal vestibular ocular reflex then the eighth cranial nerve is not affected and your exam is very concerning for a central cause of vertigo however if the reflex is not working and you observe a corrective saccade then you are reassured that cause of the vertigo is likely peripheral but you still must continue with the two other components of the hints exam to be a hundred percent sure again please note you should not apply this test to patients who have episodic vertigo or are no longer symptomatic or do not have nystagmus here’s an example of a patient with vestibular neuritis and therefore the head impulse tests showing a corrective saccade notice that when the patient’s head is moved quickly towards the left side you see a corrective saccade but you don’t see it in the other direction here’s one more example of a patient with corrective saccade and therefore a peripheral cause of vertigo a very important thing to remember is that the brain can learn to compensate for this corrective saccade and so it’s important to perform the tests randomly to avoid a false negative result also be very careful in elderly patients who may have severe neck arthritis because the rapid head movement could lead to vertebral or arterial injury the second component of the hints exam is evaluation for nystagmus ask your patient to look slightly to the left and then slightly to the right and look for Direction changing nystagmus the key here is not to have your patient focus on your finger because that can suppress the nystagmus when evaluating the stagg miss the fast component of the beating is what determines the direction look for bi directional or vertical nystagmus presence of this type of nystagmus points to a central cause of vertigo meaning stroke here’s an example of a unidirectional nystagmus which is reassuring notice that the fast phase of the beating is always towards the left no matter which direction the patient is asked to look this patient has a unidirectional nystagmus and was diagnosed with vestibular neuritis as the other components of the hints exam were also reassuring this is a pathologic bi directional nystagmus when the patient is asked to look to her right the fast phases towards the right and when the patient looks to the left the fast phase changes directions towards the left most fishes with a central cause of their vertigo do not demonstrate this finding but if it’s seen it’s highly specific for a central cause and a stroke the last component of the hints exam is the test of skew ask the patient to look at your nose and cover one eye and then move your hand quickly to cover the other eye look to see if there’s any vertical movement or diagonal or slanted movement as the eye is uncovered do this for both eyes looking at each eye at normal vertical correction is about 98% specific for a central cause of vertigo so abnormal vertical correction is bad here’s a video of the test of skew being performed on a patient the patient is asked to look at your nose and when you uncover the right eye notice that the eye is skewed and moves medially and diagonally upward to look at your nose this patient has a cerebellar stroke so to review in a patient with acute persistent vertigo and nystagmus and a normal neurologic exam a hence exam with the head impulse tests showing a corrective saccade and with unidirectional nystagmus and no abnormal test of skew means that the patient has vestibular neuritis and can possibly be discharged home on the other hand if any of the three components of the hints exam are abnormal for example no corrective saccade with head impulse testing or vertical or bi directional nystagmus or abnormal test of skew the patient needs admission to the hospital and neuroimaging so I hope you like this video absolutely make sure to check out the course this video was taken from and to register for a free trial account which will give you access to selected chapters of the course if you want to learn how met master can help you become a great clinician make sure to watch the about men mastery video so thanks for watching and I hope to see you again soon..


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