Fauquier ENT | HINTs Exam for Acute Vestibular Syndrome (Continuous Dizziness): Stroke or Vestibular Neuritis? @fauquierent | Uploaded 2 months ago | Updated 3 minutes ago
The HINTs examination, an acronym for Head Impulse, Nystagmus, and Test of Skew, is a cluster of 3 bedside tests used to evaluate a patient with acute onset dizziness that is continuously present, even when still. These tests can quickly differentiate between an inner ear vestibular problem versus central vertigo, which may be due to a stroke.
The head impulse test starts by flexing the patient’s head down slightly and moving their head slowly back and forth while having their eyes maintain fixed focus straight ahead. The head is then moved quickly and unexpectedly to one side while the patient tries to maintain straight target focus. The test is considered normal if the eyes stay focused on target without slippage.
However, if the eyes are dragged off the straight ahead target, even briefly, the test would be considered abnormal suggesting an inner ear vestibular problem. Please note that there needs to be a minimum 50% weakness of the inner ear vestibular system in order for this test to be positive.
Next, check the patient’s eyes for any nystagmus which are involuntary repetitive eye twitching. To evaluate for nystagmus, have the patient move the eyes in all the cardinal directions: left, right, up, and down.
Normally, nystagmus should be absent. However, if nystagmus is present, note which direction the eye is beating towards. The direction of nystagmus is defined by the direction of the quick phase.
An inner ear or vestibular cause for dizziness is suggested if the nystagmus is horizontal and the direction remains the same regardless of which direction the eye is looking.
A neurologic cause for dizziness is suggested if the nystagmus changes direction with eye movement. Neurologic cause for dizziness is also suggested if vertical or torsional nystagmus is present in any eye position.
The skew test, also known as the cover test, involves the patient focusing straight on a target while the clinician covers and uncovers each eye, observing for any vertical movement of the uncovered eye.
Normally, the uncovered eye remains steady. However, if it moves up or down, this indicates a vertical skew deviation, which can suggest a serious brain disorder involving the brainstem or cerebellum instead of a more benign cause due to an inner ear vestibular problem.
Collectively, when all 3 HINTs exams are performed in a dizzy patient, it is 95% accurate in identifying a central cause like stroke or peripheral origin like vestibular neuritis.
Accuracy is further increased when performing a HINTs-plus test when adding a fourth sign which is the presence of a one-sided, new-onset hearing loss which would suggest labyrinthitis.
• Intro (0:00)
• Head Impulse (0:29)
• Nystagmus (1:40)
• Test of Skew (3:10)
• HINTs Interpretation (3:46)
Video created by Dr. Christopher Chang:
https://www.FauquierENT.net
References
Usage of the HINTS exam and neuroimaging in the assessment of peripheral vertigo in the emergency department. J Otolaryngol Head Neck Surg. 2018;47:54. ncbi.nlm.nih.gov/pmc/articles/PMC6131950
HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009 Nov;40(11):3504-10. ncbi.nlm.nih.gov/pmc/articles/PMC4593511
H.I.N.T.S. to Diagnose Stroke in the Acute Vestibular Syndrome—Three-Step Bedside Oculomotor Exam More Sensitive than Early MRI DWI. Stroke. 2009 Nov; 40(11): 3504–3510. ncbi.nlm.nih.gov/pmc/articles/PMC4593511
Actor Credit:
MJ Gordon @marinjayden
Certified Yoga Alliance Instructor (RYP500, RPYT, Yin)
Certified Fitness Instructor NCEP
https://www.MJ-Gordon.com
Still haven’t subscribed to Fauquier ENT on YouTube? ►► bit.ly/35SazwA
The HINTs examination, an acronym for Head Impulse, Nystagmus, and Test of Skew, is a cluster of 3 bedside tests used to evaluate a patient with acute onset dizziness that is continuously present, even when still. These tests can quickly differentiate between an inner ear vestibular problem versus central vertigo, which may be due to a stroke.
The head impulse test starts by flexing the patient’s head down slightly and moving their head slowly back and forth while having their eyes maintain fixed focus straight ahead. The head is then moved quickly and unexpectedly to one side while the patient tries to maintain straight target focus. The test is considered normal if the eyes stay focused on target without slippage.
However, if the eyes are dragged off the straight ahead target, even briefly, the test would be considered abnormal suggesting an inner ear vestibular problem. Please note that there needs to be a minimum 50% weakness of the inner ear vestibular system in order for this test to be positive.
Next, check the patient’s eyes for any nystagmus which are involuntary repetitive eye twitching. To evaluate for nystagmus, have the patient move the eyes in all the cardinal directions: left, right, up, and down.
Normally, nystagmus should be absent. However, if nystagmus is present, note which direction the eye is beating towards. The direction of nystagmus is defined by the direction of the quick phase.
An inner ear or vestibular cause for dizziness is suggested if the nystagmus is horizontal and the direction remains the same regardless of which direction the eye is looking.
A neurologic cause for dizziness is suggested if the nystagmus changes direction with eye movement. Neurologic cause for dizziness is also suggested if vertical or torsional nystagmus is present in any eye position.
The skew test, also known as the cover test, involves the patient focusing straight on a target while the clinician covers and uncovers each eye, observing for any vertical movement of the uncovered eye.
Normally, the uncovered eye remains steady. However, if it moves up or down, this indicates a vertical skew deviation, which can suggest a serious brain disorder involving the brainstem or cerebellum instead of a more benign cause due to an inner ear vestibular problem.
Collectively, when all 3 HINTs exams are performed in a dizzy patient, it is 95% accurate in identifying a central cause like stroke or peripheral origin like vestibular neuritis.
Accuracy is further increased when performing a HINTs-plus test when adding a fourth sign which is the presence of a one-sided, new-onset hearing loss which would suggest labyrinthitis.
• Intro (0:00)
• Head Impulse (0:29)
• Nystagmus (1:40)
• Test of Skew (3:10)
• HINTs Interpretation (3:46)
Video created by Dr. Christopher Chang:
https://www.FauquierENT.net
References
Usage of the HINTS exam and neuroimaging in the assessment of peripheral vertigo in the emergency department. J Otolaryngol Head Neck Surg. 2018;47:54. ncbi.nlm.nih.gov/pmc/articles/PMC6131950
HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009 Nov;40(11):3504-10. ncbi.nlm.nih.gov/pmc/articles/PMC4593511
H.I.N.T.S. to Diagnose Stroke in the Acute Vestibular Syndrome—Three-Step Bedside Oculomotor Exam More Sensitive than Early MRI DWI. Stroke. 2009 Nov; 40(11): 3504–3510. ncbi.nlm.nih.gov/pmc/articles/PMC4593511
Actor Credit:
MJ Gordon @marinjayden
Certified Yoga Alliance Instructor (RYP500, RPYT, Yin)
Certified Fitness Instructor NCEP
https://www.MJ-Gordon.com
Still haven’t subscribed to Fauquier ENT on YouTube? ►► bit.ly/35SazwA
