RESEARCH ARTICLE

Comparison of acute vertigo diagnosis and

treatment practices between
otolaryngologists and non-otolaryngologists:
A multicenter scenario-based survey
Kenji Numata ID1, Takashi Shiga2*, Kazuhiro Omura3, Akiko Umibe4, Eiji Hiraoka5,
Shunsuke Yamanaka6, Hiroyuki Azuma7, Yasuhiro Yamada8, Daiki Kobayashi9
a1111111111 1 Department of Emergency Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Todaijima, Urayasu
a1111111111 city, Chiba, Japan, 2 Department of Emergency Medicine, International University of Health and Welfare,
a1111111111 Mita hospital, Mita, Minato-ku Tokyo, Japan, 3 Department of Otorhinolaryngology, The Jikei University
a1111111111 School of Medicine, Nishi-shimbashi, Minato-ku, Tokyo, Japan, 4 Department of Otorhinolaryngology,
Dokkyo Medical University Saitama Medical Center, Minamikoshigaya, Koshigaya city, Saitama, Japan,
a1111111111 5 Department of General Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Todaijima, Urayasu city,
Chiba, Japan, 6 Department of Emergency Medicine, University of Fukui Hospital, Matsuokashimoaizuki,
Eiheiji-cho, Yoshida-gun, Fukui, Japan, 7 Department of Emergency Medicine, Fukui prefectural hospital,
Fukui, Fukui prefecture, Japan, 8 Department of General Internal Medicine, National Hospital Organization
Tokyo Medical Center, higashigaoka, meguro-ku, Tokyo, Japan, 9 Division of General Internal Medicine,
OPEN ACCESS St. Luke’s International Hospital, Tokyo Japan

Citation: Numata K, Shiga T, Omura K, Umibe A, * [email protected]

Hiraoka E, Yamanaka S, et al. (2019) Comparison
of acute vertigo diagnosis and treatment practices
between otolaryngologists and non-
otolaryngologists: A multicenter scenario-based Abstract
survey. PLoS ONE 14(3): e0213196. https://doi.
org/10.1371/journal.pone.0213196 Acute vertigo is a common problem in emergency departments. However, clinical strategies
of acute vertigo care vary among care providers. The aim of the study was to investigate dif-
Editor: Diego Kaski, University College London,
UNITED KINGDOM ferences in diagnosis [Dix-Hallpike test, the head impulse, nystagmus, and the test of skew
(HINTS) procedure, and imaging modalities] and treatment (pharmacological treatments and
Received: October 24, 2018
the Epley maneuver) by otolaryngologists and non-otolaryngologists in emergency medicine
Accepted: February 16, 2019
settings. We used a multicenter case-based survey for the study. Four clinical vignettes of
Published: March 7, 2019 acute vertigo (posterior canal benign paroxysmal positional vertigo, vestibular neuritis,
Copyright: © 2019 Numata et al. This is an open Meniere disease, and nonspecific vertigo) were used. Total 151 physicians from all study
access article distributed under the terms of the sites participated in the study. There were 84 non-otolaryngologists (48 emergency physi-
Creative Commons Attribution License, which
cians and 36 internists) and 67 otolaryngologists. The multivariate analysis indicated that oto-
permits unrestricted use, distribution, and
reproduction in any medium, provided the original laryngologists ordered fewer CT scans (odds ratio (OR), 0.20; 95% confidence interval (CI),
author and source are credited. 0.07–0.53) and performed fewer HINTS procedures (OR, 0.17; 95% CI, 0.06–0.46), but used
Data Availability Statement: The Ethics the Dix-Hallpike method more often (OR, 2.36; 95% CI, 1.01–5.52) for diagnosis compared
Committee of the Tokyo Bay Urayasu/Ichikawa to non-otolaryngologists. For treatment, otolaryngologists were less likely to use the Epley
Hospital (approval number: 226) approved this method (OR, 0.19; 95% CI, 0.07–0.53) and metoclopramide (OR, 0.09; 95% CI, 0.01–0.97)
study, including provisions for data sharing.
and more likely to use sodium bicarbonate (OR, 20.50; 95% CI, 6.85–61.40) compared to
Section 9 ethical considerations mandate that there
are restrictions on the availability of data due to the non-otolaryngologists. We found significant differences in the acute vertigo care provided by
consent agreements for data security as well as the non-otolaryngologists and otolaryngologists from a vignette-based research. To improve
IRB approval, which allow access only to external acute vertigo care, educational systems focusing on acute vertigo are needed.
researchers for research monitoring purposes. A
non-author contact for requesting data access is as
follows: [email protected].

PLOS ONE | https://doi.org/10.1371/journal.pone.0213196 March 7, 2019 1 / 12

 Comparison of acute vertigo care practices between otolaryngologists and non-otolaryngologists

Funding: The authors received no specific funding Introduction

for this work.
Acute vertigo is a common and challenging problem encountered in the departments of otolar-
Competing interests: The authors have declared
yngology, emergency medicine (EM), and internal medicine (IM). More than one-third of
that no competing interests exist.
Americans visit a health care provider for dizziness during their life-time [1]. Vertigo is one of
the most common complaints in the emergency department (ED) and is responsible for 2.5% of
ED visits [2–4]. The psychological impact of vertigo can significantly affect an individual’s life-
style. Patients with vertigo have had to quit, change, or modify their job because of their symp-
toms [5]. Appropriate treatment is important to lead the patients to complete recovery [6].
However, there is variation in the guidelines regarding acute vertigo diagnosis and manage-
ment in several specialties. Inconsistency in the available literature has also hindered the emer-
gence of a consensus in the evidence used in each guideline. Grill et al. [7] reported that
different diagnostic tests, pharmacological therapies, or therapeutic maneuvers were used
prior to the referral of vertigo patients to a specialist.
One of the reasons for such variation in acute vertigo care might be related to differences in
practice between different specialties. In the field of IM, Lerang et al. [8] reported that rheuma-
tologists and non-rheumatologists used different diagnosis and treatment approaches for sys-
temic lupus erythematosus.
There is a possibility that the differences in practice between specialists might result in
increased use of resources and cost. However, there is little scientific evidence describing the
differences in the type or the quality of acute vertigo care between different specialists. The
present study may provide important and new insights to improve acute vertigo care in Japan.
Based on the available literature reports, we hypothesized the presence of significant differ-
ences in practice between otolaryngologists and non-otolaryngologists (EM and IM).

Materials and methods

Participants
We prospectively collected and analyzed data from the Multicenter Effort to investigate Man-
agement of vertigo In Acute Care (MEMAI). The MEMAI study is a multicenter scenario-
based survey developed to investigate the variation in acute vertigo care between different spe-
cialties, and to standardize vertigo care in Japan. We chose a sample comprising six teaching
hospitals (Tokyo Bay Urayasu/Ichikawa Medical Center, Jikei University Hospital, Dokkyo
Medical University Saitama Medical Center, Fukui Prefecture Hospital, University of Fukui
Hospital, and Tokyo Medical Center) from the Hokuriku and Kanto areas (Fukui, Tokyo, and
Saitama) in Japan. All the hospitals were equipped with more than 300 beds.
We included physicians with at least three years of postgraduate year (PGY) experience in
departments of otolaryngology, EM, and IM. The exclusion criterion was the non-filling of the
questionnaire by the participating physician. We sent a seven-page questionnaire to each
research site. Each site investigator was present during the questionnaire administration at
each hospital’s educational conference. Prior to questionnaire administration, each site investi-
gator had verbally explained in depth about the study material to the participating physicians.
Verbal consent was obtained at the same time. This study was approved by the Ethics Commit-
tee of the Tokyo Bay Urayasu/Ichikawa Hospital (approval number: 226).

Instruments
The study used a questionnaire which consisted of 50 questions and two sections. The ques-
tions were prepared by two board-certified EM physicians, two board-certified IM physicians
and two board-certified otolaryngologists, and were based on real patient situations.

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 Comparison of acute vertigo care practices between otolaryngologists and non-otolaryngologists

In the first section, the data collected included gender, post-graduate-year (PGY), specialty,
and hospital name. Physicians were also asked about their experience, knowledge, utility, and
limitations in imaging modalities used for vertigo care in their hospital.
In the second part of the questionnaire, there were four clinical vignettes of acute vertigo
care in the emergency setting. Each case consisted of a patient’s medical history, present com-
plaints, and symptoms. The clinical vignettes included 40 clinical questions regarding diagno-
sis and treatment of acute vertigo. The final diagnoses of the four vignettes were posterior
canal BPPV, vestibular neuritis, Meniere disease, and nonspecific vertigo (Supplemental
Appendix 1).

Diagnosis
Participating physicians read each scenario discussing the four types of vertigo patients with-
out knowing the final diagnosis, and were asked if they would be inclined to perform the Dix-
Hallpike test, the head impulse, nystagmus, and test of skew (HINTS), or imaging methods,
such as computed tomography (CT) or magnetic resonance imaging (MRI) as central modal-
ity, and to mark the possibility of a central cause in each case using a visual analog scale (0 =
no possibility; 100 = complete possibility).

Treatment
The Japanese clinical review published in the otorhinolaryngological society of Japan recom-
mends prescribing metoclopramide, anti-histamine, and sodium bicarbonate for acute vertigo
[9]. Physicians read the scenarios with specific information on final diagnosis and were asked
if they would prescribe any or all the following in each case; metoclopramide, antihistamine,
sodium bicarbonate, or an Epley maneuver. They were then asked the following question
regarding the final disposition: “If the symptom is not diminished after treatment, do you rec-
ommend the patient be admitted?”

Primary data analysis

We used STATA/MP 15.1 (StataCorp LLC) for the data analyses. The data, organized categori-
cally in two groups (otolaryngologist vs. non-otolaryngologist), were compared using the Fish-
er’s exact test or Mann–Whitney U test. We investigated the associations between physician
specialty and diagnostic or treatment option using multiple logistic regression analysis and
generalized linear model with a negative binomial distribution and log-link function after
covariates. We included variables in the multivariate models based on clinical plausibility and
the results of bivariate analysis if an individual p-value was less than 0.25 [10]. A p-value of
<0.05 was considered significant.

Results
Characteristics of study subjects
During the study period, 151 physicians (84 non-otolaryngologists (48 EM and 36 IM), and 67
otolaryngologists) completed the survey, giving an overall response rate of 98.0%.
Table 1 shows the background of the physicians. In bivariate analysis, gender and PGY
were similar between the groups. Otolaryngologists saw significantly more vertigo patients in a
month and non-otolaryngologists had significantly more institutional rules to obtain CT scans
prior to brain MRI.

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 Comparison of acute vertigo care practices between otolaryngologists and non-otolaryngologists

Table 1. Physician characteristics and knowledge.

Variables Total Otolaryngologist Non-otolaryngologist p value
(n = 151) (n = 84) (n = 64)
PGY, y, Median (IQR) 5.0 (4.0–8.0) 6.0 (4.0–8.0) 5.0 (3.0–9.0) 0.22
Female sex, No. (%) 32 (21.1) 18 (26.9) 14 (16.7) 0.13
Physician’s experience and knowledge about vertigo care
Number of patients/month, No. (%) by study site <0.01
1: 0/month 1 (0.7) 0 (0) 1 (1.2)
2: 1–5/month 46 (30.5) 9 (13.4) 37 (44.1)
3: 6–10/month 50 (33.1) 15 (22.4) 35 (41.7)
4: 11–20/month 22 (14.7) 14 (20.9) 8 (9.5)
5: 21/months or more 32 (21.2) 29 (43.28) 3 (3.6)
Cost of MRI, No. (%) by study site 0.60
1: 5000 yen ($44) 3 (2.0) 1 (2.8) 0 (0)
2: 15000 yen ($133) 80 (53.0) 18 (50) 27 (56.3)
3: 50000 yen ($444) 60 (40.0) 15 (41.7) 20 (41.7)
4: 80000 yen ($710) 8 (5.3) 2 (5.6) 1 (2.1)
Detection of CT by study site 0.76
1: 1% 38 (25.2) 3 (8.3) 16 (33.3)
2: 2% 32 (21.2) 10 (27.8) 11 (22.9)
3: 5% 44 (29.1) 14 (38.9) 10 (20.8)
4: 10% 31 (20.1) 9 (25.0) 8 (16.7)
5: 30% 6 (4.0) 0 (0) 3 (6.3)
Rule to take head CT before brain MRI, No. (%) by study site 20 (13.4) 3 (8.3) 14 (30.4) <0.01
Limitation in obtaining brain MRI by study site 0.30
1: Available for 24 hours 82 (54.3) 17 (47.2) 27 (56.3)
2: Some limitation but available for 24 hours 59 (39.1) 13 (36.1) 19 (39.6)
3: No limitation but cannot take MRI at night 6 (4.0) 2 (5.6) 2 (4.2)
4: Only obtain MRI in daytime with some limitation 4 (2.7) 4 (11.1) 0 (0)
5: Without MRI 0 (0) 0 (0) 0 (0)

IQR, interquartile range; CT, computed tomography; MRI, magnetic resonance imaging; PGY, post graduate year.

https://doi.org/10.1371/journal.pone.0213196.t001

Bivariate analysis
Tables 2 and 3 show the results of bivariate analysis of vertigo diagnosis and treatment. In the
diagnosis section, otolaryngologists preferred significantly fewer head CT scans for the cases of
posterior canal BPPV (otolaryngologist (30.0%), non-otolaryngologist (50.6%), p < 0.01) and
nonspecific vertigo (otolaryngologist (61.2%), non-otolaryngologist (85.6%), p < 0.01), and
were less likely to perform a HINTS procedure for the case of vestibular neuritis (otolaryngolo-
gist (62.5%), non-otolaryngologist (84.3%), p < 0.01). Otolaryngologists preferred brain MRI
significantly more often for the case of vestibular neuritis (otolaryngologist (41.8%), non-oto-
laryngologist (17.9%), p < 0.01) and the Dix-Hallpike test for the case of nonspecific vertigo
(otolaryngologist (72.7%), non-otolaryngologist (50.6%), p < 0.01). Otolaryngologists were
more likely to suspect central causes in the case of posterior canal BPPV (otolaryngologist
(8.9%), non-otolaryngologist (8.4%), p < 0.05).
In the treatment section, otolaryngologists were significantly less likely to use the Epley
maneuver to treat posterior canal BPPV (otolaryngologist (61.2%), non-otolaryngologist
(90.5%), p < 0.01) or nonspecific vertigo (otolaryngologist (6.0%), non-otolaryngologist
(16.7%), p = 0.04). In addition, otolaryngologists had lesser preference for metoclopramide to

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 Comparison of acute vertigo care practices between otolaryngologists and non-otolaryngologists

Table 2. Results of bivariate analysis in diagnosis by physician type.

Total Otolaryngologist (n = 84) Non-otolaryngologist (n = 64) p value
(n = 151)
BPPV
Perform head CT, No. (%) 62 (41.3) 20 (30.0) 42 (50.6) <0.01
Perform brain MRI 26 (17.3) 16 (23.9) 10 (12.1) 0.08
Perform Dix–Hallpike test, No. (%) 142 (94.0) 62 (92.5) 80 (95.2) 0.51
Perform HINTS procedure, No. (%) 105 (72.4) 44 (69.8) 61 (74.4) 0.58
Percentage of central causes, mean. (SD) 10.2 (8.6) 9.0 (8.9) 11.2 (8.4) <0.05
Vestibular neuritis
Perform head CT, No. (%) 61 (40.4) 26 (38.8) 35 (41.7) 0.74
Perform brain MRI 43 (28.5) 28 (41.8) 15 (17.9) <0.01
Perform Dix–Hallpike test, No. (%) 78 (51.7) 35 (52.2) 43 (51.2) 1.00
Perform HINTS procedure, No. (%) 110 (74.8) 40 (62.5) 70 (84.3) <0.01
Percentage of central causes, mean. (SD) 11.7 (10.1) 12 (8.2) 11.5 (11.4) 0.25
Meniere disease
Perform head CT, No. (%) 36 (24.0) 15 (22.4) 21 (25.3) 0.71
Perform brain MRI 24 (16.0) 15 (22.4) 9 (10.8) 0.07
Perform Dix–Hallpike test, No. (%) 79 (52.7) 41 (61.2) 38 (45.8) 0.07
Perform HINTS procedure, No. (%) 95 (65.1) 39 (60.9) 56 (68.3) 0.39
Percentage of central causes, mean. (SD) 12.3 (11.7) 13.2 (12.1) 11.5 (11.4) 0.31
Nonspecific vertigo
Perform head CT, No. (%) 112 (74.7) 41 (61.2) 71 (85.6) <0.01
Perform brain MRI 96 (64) 44 (65.7) 52 (62.7) 0.74
Perform Dix–Hallpike test, No. (%) 90 (60.4) 48 (72.7) 42 (50.6) <0.01
Perform HINTS procedure, No. (%) 103 (71.0) 45 (70.3) 58 (71.6) 1.00
Percentage of central causes, mean. (SD) 25.2 (19.2) 25.2 (19.3) 25.2 (19.2) 0.86

BPPV, benign paroxysmal positional vertigo; CT, computed tomography; MRI, magnetic resonance imaging; HINTS the Head Impulse, Nystagmus, Test of Skew
procedure.

https://doi.org/10.1371/journal.pone.0213196.t002

treat vestibular neuritis (otolaryngologist (88.1%), non-otolaryngologist (98.8%), p < 0.01).

Otolaryngologists had a significantly greater preference for sodium bicarbonate to treat poste-
rior canal BPPV (OR, 4.3; 95% CI, 2.11–8.75; p < 0.01), vestibular neuritis (OR, 26.1; 95% CI,
9.81–69.1; p < 0.01), Meniere disease (OR, 21.8; 95% CI, 8.27–57.2; p < 0.01), or nonspecific
vertigo (OR, 7.95; 95% CI, 3.76–16.8; p < 0.01).

Multivariate analysis
Responses to four baseline questions (gender, PGY, the total number of vertigo patients seen
in a month, and institutional rules to obtain CT scan prior to brain MRI) in the first section
had a p-value <0.25 in bivariate analysis. For the multivariate analysis, we decided to adjust
for gender, PGY, and the total number of vertigo patients seen in a month, based on clinical
plausibility [10]. There was a large difference in the total number of vertigo patients seen in a
month between otolaryngologist and non-otolaryngologist. This may cause different effects on
outcomes, we evaluated the interactions of the total number of vertigo patients seen in a
month for the relation between outcomes and confounders. However, we did not find any
interaction. For the questions regarding imaging modalities such as CT or MRI, we asked the
additional question “Do you have an institutional rule that physicians must not take brain
MRI without brain CT scan?” After the adjustment, we found that responses to twelve

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 Comparison of acute vertigo care practices between otolaryngologists and non-otolaryngologists

Table 3. Results of bivariate analysis in treatment by physician type.

Total Otolaryngologist (n = 84) Non-otolaryngologist (n = 64) p value
(n = 151)
BPPV
Prescribe metoclopramide, No. (%) 106 (70.2) 38 (56.7) 68 (81.0) <0.01
Prescribe anti-histamine, No. (%) 100 (66.2) 42 (62.7) 58 (69.1) 0.41
Prescribe sodium bicarbonate, No. (%) 61 (40.4) 39 (58.2) 22 (26.2) <0.01
Prescribe Epley maneuver, No. (%) 117 (77.5) 41 (61.2) 76 (90.5) <0.01
Recommend admitting, No. (%) 81 (54.0) 26 (39.4) 55 (65.5) <0.01
Vestibular neuritis
Prescribe metoclopramide, No. (%) 142 (94.0) 59 (88.1) 83 (98.8) <0.01
Prescribe anti-histamine, No. (%) 116 (76.8) 55 (82.1) 61 (72.6) 0.17
Prescribe sodium bicarbonate, No. (%) 85 (56.3) 61 (91.0) 24 (28.6) <0.01
Prescribe Epley maneuver, No. (%) 8 (5.3) 1 (1.5) 7 (8,3) 0.08
Recommend admitting, No. (%) 137 (90.7) 66 (98.5) 71 (84.5) <0.01
Meniere disease
Prescribe metoclopramide, No. (%) 109 (72.2) 44 (65.7) 65 (77.4) 0.14
Prescribe anti-histamine, No. (%) 113 (74.8) 53 (79.1) 60 (71.4) 0.35
Prescribe sodium bicarbonate, No. (%) 88 (58.3) 61 (91.4) 27 (32.1) <0.01
Prescribe Epley maneuver, No. (%) 9 (6.0) 3 (4.5) 6 (7.1) 0.73
Recommend admitting, No. (%) 98 (64.9) 44 (65.7) 54 (64.3) 1.00
Nonspecific vertigo
Prescribe metoclopramide, No. (%) 97 (64.2) 39 (58.2) 58 (69.5) 0.18
Prescribe anti-histamine, No. (%) 98 (64.9) 43 (64.2) 55 (65.5) 1.00
Prescribe sodium bicarbonate, No. (%) 76 (50.3) 51 (76.1) 25 (29.8) <0.01
Prescribe Epley maneuver, No. (%) 18 (11.9) 4 (6.0) 14 (16.7) 0.04
Recommend admitting, No. (%) 97 (64.2) 37 (55.2) 60 (71.4) 0.04
https://doi.org/10.1371/journal.pone.0213196.t003

questions (three questions regarding diagnosis, and nine questions regarding treatment) con-
tinued to show statistically significant differences (Tables 4 and 5).
In the diagnosis section, otolaryngologists had a significantly lesser preference for head CT
in the case of nonspecific vertigo (OR, 0.20; 95% CI, 0.07–0.56; p < 0.01), and for the HINTS
procedure in the case of vestibular neuritis (OR, 0.16; 95% CI, 0.06–0.42; p < 0.01). We found
no significant difference in the responses to questions regarding the possibility of central causes.
In the treatment section, otolaryngologists had a significantly lesser preference for the
Epley maneuver to treat posterior canal BPPV (OR, 0.17; 95% CI, 0.06–0.47; p < 0.01) and for
metoclopramide treat posterior canal BPPV (OR, 0.26; 95% CI, 0.11–0.63; p < 0.01) or vestibu-
lar neuritis (OR, 0.09; 95% CI, 0.01–0.63; p = 0.04). Otolaryngologists had a significantly
greater preference for sodium bicarbonate to treat posterior canal BPPV (OR, 4.08; 95% CI,
1.77–9.39; p < 0.01), vestibular neuritis (OR, 19.16; 95% CI, 6.63–55.26; p < 0.01), Meniere
disease (OR, 16.24; 95% CI, 5.64–46.73; p < 0.01), or nonspecific vertigo (OR, 9.61; 95% CI,
3.80–24.25; p < 0.01). Otolaryngologists were less likely to admit posterior canal BPPV
patients (OR, 0.18; 95% CI, 0.07–0.45; p < 0.01) or nonspecific vertigo patients (OR, 0.78; 95%
CI, 0.11–0.65; p < 0.01).

Discussion
To the best of our knowledge, the present study is the first to detect differences in acute vertigo
care in emergency settings between specialists.

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 Comparison of acute vertigo care practices between otolaryngologists and non-otolaryngologists

Table 4. The odds ratio and rate ratio for physician’s willingness to perform each examination and suspicion for central disease among otolaryngologists compared
to non-otolaryngologists by multivariate analyses.
Adjusted OR 95% CI of OR RR 95% CI of IRR p value
BPPV
Perform head CT 0.43 0.19–1.02 0.06
Perform brain MRI 1.61 0.54–4.76 0.39
Perform Dix–Hallpike test 0.27 0.05–1.43 0.13
Perform HINTS procedure 0.71 0.30–1.69 0.44
Percentage of central causes 0.81 0.56–1.18 0.27
Vestibular neuritis
Perform head CT 0.65 0.28–1.49 0.31
Perform brain MRI 2.01 0.81–4.98 0.13
Perform Dix-Hallpike test 0.84 0.39–1.83 0.67
Perform HINTS procedure 0.16 0.06–0.42 <0.01
Percentage of central causes 1.02 0.69–1.50 0.93
Meniere disease
Perform head CT 1.00 0.40–2.52 0.99
Perform brain MRI 1.73 0.58–5.22 0.33
Perform Dix-Hallpike test 1.95 0.88–4.31 0.10
Perform HINTS procedure 0.71 0.31–1.62 0.42
Percentage of central causes 1.10 0.75–1.61 0.63
Nonspecific vertigo
Perform head CT 0.20 0.07–0.56 <0.01
Perform brain MRI 0.73 0.31–1.71 0.47
Perform Dix-Hallpike test 2.48 1.07–5.70 0.03
Perform HINTS procedure 0.67 0.28–1.61 0.37
Percentage of central causes 0.96 0.66–1.40 0.82

OR, odds ratio; IRR, incident, rate ratio.

https://doi.org/10.1371/journal.pone.0213196.t004

Diagnosis
In multivariate analysis, even though the use of head CT for the case of nonspecific vertigo was
significantly different between otolaryngologists and non-otolaryngologists there was no sig-
nificant difference in suspicion of central causes based on the history of each scenario; this
might be a result of the physicians’ daily bedside practice. In the field of EM, Vanni et al. [11]
developed an algorithm to rule out stroke and other life-threatening diseases in acute vertigo
for use by emergency physicians. In the field of otolaryngology, Walther [12] reviewed dizzi-
ness and vertigo in otolaryngology clinics focusing on peripheral vertigo as well as a multitude
of otolaryngology-related diseases involving the inner ear such as barotrauma and fracture of
the oto-base; they emphasized the use of more sophisticated technology for accurate diagnoses.
It has been reported that unnecessary imaging tests such as head CT and brain MRI were con-
ducted in cases of posterior canal BPPV [13–15]. These findings led us to suspect that unneces-
sary imaging modalities are done in Japan.
A relatively lesser preference among otolaryngologists for the HINTS procedure in the case
of vestibular neuritis was found. The HINTS procedure was found to be more sensitive than
early diffusion-weighted MRI for stroke diagnosis [16–19]. Modern vestibular diagnostic tests
(eye movement analysis dispose of video documentation systems, etc.) were able to provide
objective information [12]. There is possibility that otolaryngologists substitute these tests for
the HINTS procedure, and factors such as lack of dissemination of the HINTS procedure and

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 Comparison of acute vertigo care practices between otolaryngologists and non-otolaryngologists

Table 5. The odds ratio and for physician’s willingness to perform each treatment and disposition among otolar-
yngologists compared to non-otolaryngologists by multivariate analyses.
Adjusted OR 95%CI of OR p value
BPPV
Prescribe metoclopramide, No. (%) 0.26 0.11–0.63 <0.01
Prescribe anti-histamine, No. (%) 0.49 0.21–1.12 0.09
Prescribe sodium bicarbonate, No. (%) 4.08 1.77–9.39 <0.01
Prescribe Epley maneuver, No. (%) 0.17 0.06–0.47 <0.01
Recommend admitting, No. (%) 0.18 0.07–0.45 <0.01
Vestibular neuritis
Prescribe metoclopramide, No. (%) 0.09 0.01–0.88 0.04
Prescribe anti-histamine, No. (%) 0.96 0.38–2.46 0.95
Prescribe sodium bicarbonate, No. (%) 19.16 6.63–55.26 <0.01
Prescribe Epley maneuver, No. (%) 0.29 0.03–3.14 0.31
Recommend admitting, No. (%) 4.99 0.59–42.29 0.14
Meniere disease
Prescribe metoclopramide, No. (%) 0.65 0.28–1.54 0.33
Prescribe anti-histamine, No. (%) 0.86 0.35–2.11 0.74
Prescribe sodium bicarbonate, No. (%) 16.24 5.64–46.73 <0.01
Prescribe Epley maneuver, No. (%) 1.12 0.23–5.53 0.89
Recommend admitting, No. (%) 0.75 0.32–1.72 0.49
Nonspecific vertigo
Prescribe metoclopramide, No. (%) 0.59 0.26–1.33 0.20
Prescribe anti-histamine, No. (%) 0.56 0.24–1.29 0.17
Prescribe sodium bicarbonate, No. (%) 9.61 3.80–24.25 <0.01
Prescribe Epley maneuver, No. (%) 0.47 0.12–1.79 0.27
Recommend admitting, No. (%) 0.27 0.11–0.65 <0.01
https://doi.org/10.1371/journal.pone.0213196.t005

its evidence among otolaryngologists may have influenced this finding. Future studies are
needed to explore instituting a training program for the HINTS procedure and to determine
whether it decreases use of unnecessary brain MRIs and the relevant costs and time.
Other studies have reported that the cause of the highest number of referrals from the ED to
the otolaryngology clinic was peripheral vertigo, and that the most frequent referral diagnosis
was nonspecific vertigo [20]. In such cases, otolaryngologists make a specific diagnosis upon
examination. It was reported that posterior canal BPPV and vestibular migraine are the most
frequently missed etiologies of vertigo, and that the Dix-Hallpike test is the most reliable diag-
nostic test for posterior canal BPPV [18, 19, 21–23]. Therefore, otolaryngologists may prefer to
use the Dix-Hallpike test in cases of nonspecific vertigo to diagnose posterior canal BPPV.

Treatment
In Japan, there are no differences in physician consultation fee based on the physician special-
ties, such IM, EM, or otolaryngology [24]. In our questionnaire, the patients with posterior
canal BPPV, vestibular neuritis, and Meniere disease complained of nausea. Although meto-
clopramide is anti-emetic and not an anti-vertigo medication, non-otolaryngologists preferred
prescribing metoclopramide in the case of posterior canal BPPV. This might have also been
caused by differences in the daily bedside practice. In the ED, ruling out cerebellar bleeding as
a cause of vertigo is a high priority task. Non-otolaryngologists tend to control the symptoms
of the patients prior to CT in an acute manner. Therefore, non-otolaryngologists might prefer

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 Comparison of acute vertigo care practices between otolaryngologists and non-otolaryngologists

prescribing metoclopramide in cases of posterior canal BPPV or vestibular neuritis causing

nausea.
There has been evidence showing that the Epley maneuver was more efficient in treating
posterior canal BPPV than placebo and/or drug therapy alone with or without intervention
[25, 26]. However, only 60% otolaryngologists were willing to perform Epley maneuver for
posterior canal BPPV in our study. We believe it is possible that the Japanese otolaryngologist
were less inclined to perform the Epley maneuver because of their overwhelming outpatient
volume as well as time burden from the Epley maneuver. However, the Epley maneuver is a
well-established and cost-effective treatment method, therefore we should strongly emphasize
its effectiveness nationwide. Another possibility is that lack of educational systems which
caused lack of knowledge about treatment for posterior canal BPPV. Physicians in otolaryngol-
ogy clinics should make time for and learn the Epley maneuver to decrease unnecessary
admission.
A meta-analysis shows the efficacy for chronic vertigo symptoms and reviews of emergency
medicine also recommend using anti-histamine for acute vertigo care [2, 27, 28]. However,
only 64.9%– 76.8% otolaryngologists and non-otolaryngologists are willing to prescribe anti-
histamine for acute vertigo patients in our study. We need to establish educational systems to
disseminate knowledge about efficacy of anti-histamine.
Bivariate analysis showed that at least 25% of the otolaryngologists and non-otolaryngolo-
gists were willing to prescribe sodium bicarbonate to treat vertigo patients. Matsunaga et al.,
and Kawabata et al., [29, 30] in their animal model-based study, observed the efficacy of
sodium bicarbonate in vertigo treatment. Aoki [9] commented that the mechanism of sodium
bicarbonate action on vertigo was unclear. However, he described two possible mechanisms;
dilation of the inner ear’s blood vessels and improvement in acidemia in the inner ear; he sur-
mised that these mechanisms could underlie the treatment of vertigo using sodium bicarbon-
ate. Multivariate analysis revealed that otolaryngologists were significantly more willing to
prescribe sodium bicarbonate to treat vertigo patients than non-otolaryngologists. We infer
that Japanese otolaryngologists prefer using sodium bicarbonate to treat various types of ver-
tigo even with limited in vitro evidence.

Limitations
The present study had several limitations. The first was regarding the external validity; even
though the study sites were carefully selected to represent geographic diversity, the risk of
selection bias should be considered; the sites were all teaching hospitals. Although we found
multiple significant differences in acute vertigo care among the specialists, the limited sample
size should be considered.
The second limitation was the limited diagnostic skills of the participating physicians. In
the diagnosis, to avoid anchoring bias, we intentionally avoided disclosing the final diagnosis
in each scenario. Consequently, some of the participating physicians with limited diagnostic
skills may not have been able to accurately identify symptom patterns and, thus, the final diag-
nosis. It is also possible that the participants who read the scenarios in the treatment realized
the final diagnosis of each case retrospectively.
The third limitation was that we used questionnaires that were used in a survey investigat-
ing theoretical diagnostics and treatments on hypothetical patients. Therefore, the actual prac-
tice pattern might have been not reflected.
The forth limitation was multiple comparison. We performed the survey with 50 questions
and multiple analyses. We might need to consider that our results could be positive because of
multiple comparisons.

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 Comparison of acute vertigo care practices between otolaryngologists and non-otolaryngologists

The fifth limitation was regarding the potential confounders. We included study variables
based on prior knowledge [10]. However, the possibility of unknown confounders not
included in this study should be considered.
The sixth limitation was that these results may not be generalizable because this study is
based on the Japanese clinical context and the emergency vertigo care in each country is differ-
ent from that of the Japanese practice.

Conclusion
There were significant differences in acute vertigo diagnosis and treatment practices between
non-otolaryngologists and otolaryngologists from a vignette-based research. These differences
might be caused due to variations in the guideline of each specialty. To improve acute vertigo
care in Japan, standardized educational systems for acute vertigo are needed.

Supporting information
S1 Table. The survey questions used in the study, in English translation and the original
language.
(DOCX)

Acknowledgments
I would like to thank all participating physicians for answering the questionnaire.

Author Contributions
Conceptualization: Kenji Numata, Takashi Shiga.
Data curation: Kenji Numata, Kazuhiro Omura, Akiko Umibe, Eiji Hiraoka, Shunsuke Yama-
naka, Hiroyuki Azuma, Yasuhiro Yamada.
Formal analysis: Kenji Numata, Daiki Kobayashi.
Investigation: Kenji Numata, Daiki Kobayashi.
Project administration: Takashi Shiga.
Visualization: Takashi Shiga.
Writing – original draft: Kenji Numata.

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