11/13/24, 7\:05 PM Guide | HINTS examination

HINTS examination

Table of contents

Dizziness

Dizziness is a common presentation to general practice and emergency departments, a
12-month incidence of 3%.
¹ Peripheral vestibular dysfunction is present in around 40% of dizzy patients.
² Dizziness can be
extremely frustrating and debilitating for patients, not to mention a challenge for clinicians eliciting a subjective experience that
can be di
(a sensation of giddiness), or more a sense of feeling faint (pre-syncope)?³ Having an approach that is likely to diagnose the
most common causes, while also screening for rarer but more serious possibilities, is a vital skill.
This article is focussed on an important component of the assessment of patients you suspect have true vertigo\: the HINTS
examination.

Overview of vertigo

Vertigo speci
vestibular tracts of the brainstem are dysfunctional or damaged. Patients with vertigo may also present with nausea and
vomiting, postural and gait instability, a tilt illusion (feeling that the environment is tilted), drop attacks (sensation of being
pulled to the ground), spatial disorientation, or oscillopsia. 4
Peripheral causes are far more common than central causes and
include benign paroxysmal positional vertigo (BPPV), vestibular neuronitis (or labyrinthitis), and Ménière’s disease. Central
causes can be as a result of stroke a
vestibular nuclei), multiple sclerosis, medication toxicity, trauma, posterior fossa brain tumours and migraine. Importantly, it
should be remembered that older patients have a higher incidence of central causes of vertigo (with the majority being stroke).
2
A general approach to vertigo, as well as its common dihere. For patients
with suspected benign paroxysmal positional vertigo (BPPV), a description of how to perform the Dix-Hallpike test and Epley
manoeuvre can also be found here.

Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Brie
Gain consent to proceed with the examination.
Position the patient on a chair or sitting upright on a clinical examination couch.
Ask the patient if they have any pain before proceeding with the clinical examination.

Performing the HINTS examination

Determining whether vertigo is of peripheral or central origin is critical. Taking a detailed history regarding the onset, tempo,
prior episodes, associated symptoms and relevant risk factors is the
a good history, the HINTS examination is a useful tool in detecting acute, time-sensitive, central causes of vertigo, including
posterior circulation strokes like lateral medullary syndrome. While most vertebrobasilar strokes are also accompanied by other
https\://app.geekymedics.com/osce-guides/clinical-examination/hints-examination/ 1/311/13/24, 7\:05 PM Guide | HINTS examination
signs (such as diplopia, dysarthria, dysphagia, motor and sensory de
vertigo and subtle incoordination on examination. A positive HINTS exam has been reported to have a high sensitivity and
speci
5
The HINTS exam is only used on a subset of the patients who present with\:
Persistent vertigo over hours or days
Nystagmus
A normal full neurological exam.
HINTS is comprised of three core components\: head impulse test, evaluation of nystagmus, and a test of skew.

Head-impulse test

To perform the head impulse test\:
1. Gently move the patient’s head side to side, making sure the neck muscles are relaxed.
2. Then ask the patient to keep looking at your nose whilst you turn their head left and right.
3. Turn the patient's head 10-20° to each side rapidly and then back to the midpoint.
Interpretation
A positive test indicates there is a disruption to the vestibulo-ocular re
rapidly back to the point of
the clinician's nose. If there is a corrective saccade (a positive head-impulse test) this is reassuring that the pathology is most
likely a problem with the vestibulocochlear nerve on the ipsilateral side – that is, it is peripheral and not central. It’s important
that this test is done on patients who are currently symptomatic. Patients who are not symptomatic at the time of examination
will likely have normal clinical
There are some important and common-sense contraindications for the head-impulse test to consider, including head and
neck trauma and severe cervical spine osteoarthritis.

Nystagmus

To assess nystagmus\:
1. Observe the patient's primary gaze while they look straight ahead.
2. Then ask the patient to look to the left and to the right without
Interpretation
The direction of the saccadic eye movement is important.
Unidirectional nystagmus is reassuring and more likely to be of peripheral origin. When nystagmus changes direction or is
vertical, it is much more likely to be associated with central pathologies.
Bidirectional nystagmus, in particular, is highly speci
that the patient is looking, then changes direction with their gaze (gaze-evoked nystagmus).

Test of skew

To perform the test of skew\:
1. Ask the patient to look at your nose and subsequently cover one of their eyes.
2. Then, quickly move your hand to cover the patient's other eye. During this process, observe the uncovered eye for any
vertical and/or diagonal corrective movement.
3. Repeat this manoeuvre on the other eye.
Interpretation
Any abnormal movement observed here, often associated with vertical diplopia, is highly speci
vertigo.

Summary

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In summary, with an otherwise normal neurological exam, ascertaining the peripheral and central causes of vertigo using
HINTS exam can be summarised in Table 1.
Table 1. Distinguishing peripheral vs central vertigo using the HINTS examination
Peripheral Central
Head impulse test Abnormal Normal
Nystagmus None or unidirectional Bidirectional or vertical
Test of skew No vertical skew Vertical skew
There are some excellent videos on YouTube which show real-life examples of clinical
Johns, an Emergency Physician at the University of Ottawa, has some clearly explained videos.

To complete the examination...

Explain to the patient that the examination is now
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Summarise your

Reviewers

Prof Merrilee Needham
Consultant Neurologist
Prof Peter Friedland
Consultant ENT Surgeon

References

1. Neuhauser H.K. The Epidemiology of Vertigo and Imbalance. Published in 2013. Available from\: [LINK].
2. Branch, Jr. W.T., Barton, J.J.S. Approach to the patient with dizziness. Published in 2020. Available from\: [LINK].
3. Dommaraju, S., Perera, E. An Approach to Vertigo in General Practice. Published in 2016. Available from\: [LINK].
4. Furman, J.M. Barton, J.J.S. Evaluation of the patient with vertigo. Published in 2015. Available from\: [LINK].
5. Kattah, J.C., Talkad, A.V., Wang, D.Z. et al. H.I.N.T.S to Diagnose Stroke in the Acute Vestibular Syndrome – Three-Step Bedside
Oculomotor Exam More Sensitive than Early MRI DWI. Published in 2009. Available from\: [LINK].
Source\: geekymedics.com
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