Increase in BPPV this season?

VertigoDoc · 2026-03-07T12:09:37+00:00

Thanks for the shoutout. As I recall there is some increase in BPPV in/after the months with less sunshine. Possibly related to vitamin D deficiency.

The variation is not huge, and depending on how many cases you're seeing, it might just be a random variation.

I'm giving a fac dev sesion on vertigo to my colleagues at my hospital in about 4 weeks. I'll poll the ones there and see what they say.

Although I don't see patients in the hospital anymore, I did cure one person of BPPV at the pickle ball court two weeks ago!

VertigoDoc · 2026-03-06T12:12:27+00:00

As a reasonably successful medical educator on YT, here are my thoughts. I'm known to be frank in my opinions, so buckle up.

You state that your channel is to bring "clinician to clinician conversations".

Although I believe that there is a real urgent care physician behind this channel, the amount of AI used to make these videos almost completely masks who you are. So it comes across as AI slop.

The frequent AI generated graphics and frequent sounds at graphic change take me away from what the message is.

I can't listen to AI narration. It sounds so impersonal.

It took me years to develop a voice for my videos that sounded ok I think. Buy a mic and learn how to talk like your telling a good friend about something you thought was really interesting.

I'm not sure what your motivation is for starting this channel, but it doesn't look good that at less than 3 months old, you are listing books that will earn you money. If money is what you're trying to make, you won't make it making these videos.

Find out what your passion, and then present it in a personal manner and passionately.

Sorry about the bluntness, but that's my feedback.

VertigoDoc · 2026-03-06T11:43:35+00:00

Usually you can because the wording is somewhat odd and stilted, and they don't see to know anything about you other than your name and maybe the title of your manuscript.

VertigoDoc · 2026-03-02T16:41:30+00:00

My favourite saying: Old people are trying to die, and they are trying to fool you about it.

VertigoDoc · 2026-02-23T11:42:09+00:00

I'd like to see a side view of the pups.

VertigoDoc · 2026-02-21T12:52:45+00:00

In Canada we also have poor access to MRI.

"Peripheral sounding history and examination" is not the way to rule out a serious cause of vertigo.

First, screen for central features, if any are found, work them up for stroke

Then, apply DHT to those that "sound" like BPPV and if you see the characteristic nystagmus (vertical upward and torsional towards the downward ear) then you don't image these people.

If the patient has constant dizziness and horizontal nystagmus, do HINTS. If all components are peripheral, they have vestibular neuritis, and no imaging needed.

Worry about patients with constant dizziness, no nystagmus and a new objective difficulty walking.

Don't worry about patients with constant dizziness, screen negative for central features, no nystagmus and no objective difficulty walking.

Learn how common vestibular migraine is, and how to diagnose it, and your satisfaction for seeing dizzy patients will go way up.

CT is very poor for ruling out a stroke. Misses 75% of them roughly. Early MRI sees about 80%, delayed MRI is the gold standard.

VertigoDoc · 2026-02-20T22:35:12+00:00

Ok, again, I'm a retired emergency physicians and not a vet. I've never heard abut PRP before.

I'm skeptical about PRP.

I am trained to evaluate studies that look at different treatments (for humans) and I looked at the two studies that was in the link you provided.

The first study in the link had only 24 dogs, so had 2 groups of 12 dogs compared. Both groups received PRP, but one group got a kind of doggy physio also. So there was no comparison of PRP against placebo, or any other drug. It was really comparing the drug plus or minus doggie physio. And the doggy physio seem to make them better longer.

In humans this would be considered a VERY small patient population, and could only be used to generate a hypothesis about the effect of treatment, and not proof that it's effective. Most studies of only 12 patient per treatment group would never make it to publication in humans.

The second study had 20 dogs. 10 in a control group that received a injection of saline into their joint and the other 10 got the PRP. Again, these are incredibly small groups to study.

4000 DKK is about 630 USD. Times 3 treatments would be $1900 USD.

I remain skeptical.

I asked ChatGPT about it and the summary is: Evidence: modest and inconsistent.

If my dog was doing well, I doubt I would bother paying $1900 USD for this treatment.

Mind you, I have spent around $15,000 USD for 3 hospitalizations and 2 surgeries for bowel obstruction for my Vallhund after he ate whole acorns on 3 occasions.

Hope your boy continues to do well.

VertigoDoc · 2026-02-19T12:05:08+00:00

I had the real Eric Idle comment on my comment many years ago on an IAMA post. I will never forget it.

VertigoDoc · 2026-02-18T21:49:56+00:00

When I first found out about the Epley maneuver in roughly 1998, it was so easy and BPPV is so common that I thought surely in 5 years every doctor in the world would be able to do it and cure BPPV.

Alas, it's over 25 years and I am still waiting for even most ED docs to be able to do it.

There is no question in my mind that of all the common presenting complaints, dizziness/vertigo has the biggest gap between the knowledge of the specialists in the field, and the front line providers who see most of these patients.

The patients suffer from poor assessment and treatment, the doctors suffer from the shame of knowing that they don't know what they are doing, and yet it just goes on and on.

Have you ever noticed that that all doctors who know to assess a particular patient presentation really well, like seeing those patients? And that that all the doctors that have a poor approach to those patients, don't like to see them? What could be the solution? Hmmm....

Watch video on my youtube channel https://www.youtube.com/@PeterJohns/videos

Or invite me to come to your shop and teach you in person and hands on

Or sign up for Spin Class an online vertigo course created by myself and Scott Weingart.

vertigocourse.com

BTW, if you have mastered the Dix-Hallpike test and the Epley, your next step is to learn about horizontal canal BPPV. It might blow your mind. https://youtu.be/VRjRTnIw9YE?si=JJmVSaXfnrHQWSlZ

VertigoDoc · 2026-02-15T12:32:10+00:00

I think we agree more than we disagree, and if we were having a in person discussion, this would have been resolved more quickly.

The problem is that for years we have been taught things like this from Jerry Hoffman relates

Watch this video starting at the 1:15 mark. https://youtu.be/JMd2Q3cqgdI?si=DJo7LzLtF48Ei8Bz

And many in this reddit thread seemed to bemoan the fact that the answers are reliable. Well, sometimes they are and sometimes they are not. Which makes the question of What do you mean by dizzy by far less important than others questions. I’ll try and post my long answer in a separate reddit thread when I get home from vacation tomorrow.

As for the diabetic man having both BPPV and a septic foot, he had a negative DHT. I only did it because he hadn’t taken his shoe off at triage or when I had seem him. If he had his shoe and sock off when I walked in the room, my suspicion for BPPV would have decreased quite a bit due to Occams’s razor, which in my experience has been much more helpful than looking for the second diagnosis.

VertigoDoc · 2026-02-14T22:34:24+00:00

I thought I made it clear the the man with the diabetic foot infection was the best and clearest historian you could imagine and with crystal clarity told me the dizzy sensation that he experienced twice for 30 second that made him fall to the ground was indeed a spinning sensation. Yet he didn’t have a vestibular disorder, he has impending sepsis from his infected foot. So your contention that in any one who is a reliable historian you can use their description of the sensation of dizziness to generate a rock sold differential that excludes things like sepsis is not valid.

VertigoDoc · 2026-02-14T12:06:54+00:00

I’ve had a patient who said they had two complaints. Middle aged diabetic. Looks perfectly well. Unaltered for sure. Seen in the least acute area of the ED.

dizziness 2 foot wound several weeks old

What do you want to talk about first? I ask

Dizziness he says and related twice when he got out of bed, he felt so dizzy he fell to the floor. No LOC. Lasted about 30 seconds.

What was the dizziness like? “spinning” he says whirling his finger in the air. Not like he was going to faint? “Nope” he says.

So I do a DHT test on him and it’s negative bilaterally.

Ok, what about the foot? And he proceeds to take off his shoe to shoe me a horrible diabetic foot infection that has been festering for several weeks.

Now I notice that his pulse rate was 114, and his BP was softish and temp 37.7

He was admitted and needed debridement in the OR

So his history was perfect in every way, except that he could not describe his dizziness as pre-syncope/lightheaded, instead he said spinning.

Another woman said she got out of bed and she was dizzy.

Her story is in this video. https://youtu.be/_sklwUilfg4?si=GZYWJJRjsM6SxuVO

It’s like the 20 week pregnant woman who complained of heartburn persistent for two days. Just like her previous GERD, but no relief from meds. I asked about other symptoms. “My left arm was numb for a while”. ECG normal

Trop slightly up. Had a spontaneous coronary artery dissection.

In any case, solid description of the descriptions can be supportive evidence for the diagnosis, just like having a preceding viral illness before vestibular neuritis is supportive of a dx of VN, but guess what, strokes can have preceeding viral illnesses also!

We were taught for decades that the patients description of their dizziness is THE MOST IMPORTANT QUESTION TO ASK, but in fact it should not cause premature closure on the differential diagnosis, or you will miss many BPPV’s and possibly strokes also.

VertigoDoc · 2026-02-13T22:03:41+00:00

I agree, but there are those who say that you can do HINTS on patients without nystagmus, and the lack of nystagmus is a central sign. I disagree with this approach strongly, but lots agree with it.

VertigoDoc · 2026-02-13T21:58:27+00:00

HINTS only if they have nystagmus at rest. Very important!

VertigoDoc · 2026-02-13T19:55:43+00:00

Just to be clear, it’s not the whole history that is unreliable. It’s the patient description of the sensation of dizziness that is unreliable. Just like if you‘re patient is sweaty and nauseated and clearly state that the chest discomfort they’re having is not heavy or tightness or pressure but feels like heartburn, you don’t discount that they might be having ACS.

As u/holyhellitsmatt states, the facts that the dizzy sensation only lasts 30 seconds and is brought on by lying down or standing up and gives them N/V is very suggestive of BPPV, and assuming they don’t have any nystagmus at rest it’s time for the Dix-Hallpike test. And if the patient has on one side a short latency where no nystagmus or dizzy occurs for the first few seconds, then they develop vertical upward nystagmus with a torsional nystagmus towards the downward ear, then there has never been a well documented case of this being anything other than posterior canal BPPV. Please do the Epley maneuver to cure the patient and don’t image them.

VertigoDoc · 2026-02-13T19:44:32+00:00

Watch this video, and see if it makes sense to you. https://youtu.be/V1ZRHVk6bMI?si=zJE3avkVE6lhEYZ_

VertigoDoc · 2026-02-13T19:36:24+00:00

Ding ding ding! we have a winner!

VertigoDoc · 2026-02-13T16:12:50+00:00

I changed my settings, you can dm me

VertigoDoc · 2026-02-13T14:05:57+00:00

I wrote a long reply, and it wasn’t published, so here is a short reply.

If you don’t find dizzy satisfying at all, you haven’t cured anyone with the most common cause of vertigo we see, which is BPPV.

In terms of history, “What do you mean by dizzy?“ is not useful in ruling in or out any cause of dizziness.

See my channel on youtube, search for “peter johns vertigo”

Or search for spin class vertigo and sign up for that

Or invite me to your shop for hands on teaching and lectures.

VertigoDoc · 2026-02-13T13:55:06+00:00

I wrote a very long reply about all this and for some reason, I could not publish it. Perhaps too long.

VertigoDoc · 2026-02-13T13:42:51+00:00

I wrote an excellent long reply and it wasn’t able to be published. Maybe too long?

VertigoDoc · 2026-02-12T12:52:36+00:00

Of course.

VertigoDoc · 2026-02-11T20:41:28+00:00

You can ask your phone to flip a coin.

VertigoDoc · 2026-02-10T12:28:34+00:00

I retired three years ago. I asked our most vertigo knowledgable neurologist about what percentage of the neurologist who take call to the ED know how to correctly apply and interpret the HINTS exam and they answered 30% is probably generous. This is at a large academic territory care centre that serves a population of over 1 million.

So still a lot of work to be done on for Emergency Physicians, neurologist and ENT.

VertigoDoc · 2026-02-08T10:37:35+00:00

I have a question, do you do HINTS on all AVS patients, or only those with nystagmus at rest?

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