Clinical Study: Otologic ManifestationsThe Impact of the COVID-19 Pandemic on
Follow-Ups for Vertigo/Dizziness Outpatients
Ear, Nose & Throat Journal
2021, Vol. 100(2S) 163S–168S
ª The Author(s) 2020
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/0145561320980186
journals.sagepub.com/home/ear
Keita Ueda, MD1, Ichiro Ota, MD, PhD1, Toshiaki Yamanaka, MD, PhD1,
and Tadashi Kitahara, MD, PhD1
Abstract
Objectives: In the present report, we aimed to investigate the impact of the coronavirus disease (COVID-19) pandemic on
vertigo/dizziness outpatient cancellations in Japan. Methods: We examined 265 vertigo/dizziness outpatients at the ear, nose,
and throat department of the Nara Medical University between March 01, 2020, and May 31, 2020, during the COVID-19
pandemic in Japan. We also focused on 478 vertigo/dizziness outpatients between March 01, 2019, and May 31, 2019, before
the COVID-19 pandemic, to compare the number of cancellations between these 2 periods. The reasons for cancellation and
noncancellation were investigated using telephone multiple-choice questionnaires (telMCQs), particularly for patients with benign
paroxysmal positional vertigo (BPPV) and Meniere’s disease (MD). Results: There were many cancellations for medical examinations during the 2020 study period. The total number of vertigo/dizziness outpatients decreased by 44.6% in the 2020 period
compared to the same period in 2019. The percent reduction in clinic attendance from 2019 to 2020 (ie, [2019-2020]/2019) for
patients with BPPV was higher than that for patients with MD. Compared to the other vertigo-associated conditions, patients with
MD exhibited a lower percent reduction in clinic attendance. According to the results of the telMCQs, 75.0% of BPPV cases and
88.2% of MD cases cancelled their appointment and gave up visiting hospitals due to fear of COVID-19 infection, even if they had
moderate to severe symptoms. On the contrary, 25.0% and 80.0% patients with BPPV and MD, respectively, did not cancel their
appointment; they should not have visited the hospital but stayed at home because they had slight symptoms. Conclusions:
These findings suggest that advanced forms should be prepared for medical care, such as remote medicine. These forms should
not only be for the disease itself but also for the mental distress caused by persistent symptoms.
Keywords
benign paroxysmal positional vertigo, COVID-19, Meniere’s disease, remote medicine, vertigo/dizziness
Introduction
The coronavirus disease (COVID-19) pandemic began in
Wuhan, China, in December 2019, and the outbreak has rapidly
spread worldwide. The first Japanese patient tested positive for
COVID-19 in Nara prefecture on January 28, 2020. The patient
was a tour bus driver and took Chinese tourists from Wuhan for
sightseeing. The World Health Organization (WHO) declared
COVID-19 to be a pandemic in March 2020.1,2 Owing to the
high risk of exposure and infection to COVID-19 from aerosol
and droplet contamination, the current COVID-19 pandemic
leads to a significant occupational hazard for physicians and
paramedical staff.3-11 Particularly, the physicians and paramedical staff in the ear, nose, and throat (ENT) department are
always at risk of being exposed to outpatients with nasal and/or
respiratory symptoms due to COVID-19. The same risk can
presumably be applied to the patients. Outpatients with
vertigo/dizziness who are COVID-19 negative may be infected
by nose and throat patients who have COVID-19 at the same
outpatient clinic. In the present report, we investigated
the impact that the COVID-19 pandemic has had on vertigo/
dizziness outpatient cancellations in Japan.
1
Department of Otolaryngology–Head and Neck Surgery, Nara Medical
University, Kashihara, Nara, Japan
Received: September 25, 2020; revised: November 13, 2020; accepted:
November 18, 2020
Corresponding Author:
Tadashi Kitahara, MD, PhD, Department of Otolaryngology–Head and Neck
Surgery, Nara Medical University, 840 Shijo-cho, Kashihara-city, Nara
634-8522, Japan.
Email: tkitahara@naramed-u.ac.jp
Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License
(https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission
provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).
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Table 1. Telephone Multiple-Choice Questionnaires (telMCQs) of
Cancellation (A) and Noncancellation (B) to Visit Hospitals.
(A) Reasons for cancellation
(a) about COVID-19
1. had a fever higher than 37.5 C (99.5F) and/or contacted
COVID-19 patients within a week
2. did care for a risk to be infected by other COVID-19
patients at hospitals
3. did not care for a risk to be infected by other COVID-19
patients at hospitals
(b) about vertigo/dizziness
1. had severe vertigo/dizziness
2. had moderate vertigo/dizziness
3. had no-slight vertigo/dizziness
(B) Reasons for non-cancellation
(a) about COVID-19
1. had a fever higher than 37.5 C (99.5F) and/or contacted
COVID-19 patients within a week
2. did care for a risk to be infected by other COVID-19
patients at hospitals
3. did not care for a risk to be infected by other COVID-19
patients at hospitals
(b) about vertigo/dizziness
1. had severe vertigo/dizziness
2. had moderate vertigo/dizziness
3. had no-slight vertigo/dizziness
Methods
This clinical study was registered with the UMIN clinical trials
registry (identification number: 000018399) and was approved
by the Ethics Committee of the Nara Medical University (identification number: 0889).
Patients
We retrospectively examined 265 vertigo/dizziness outpatients
at the ENT department of Nara Medical University between
March 1, 2020, and May 31, 2020, during the COVID-19 pandemic in Japan. We also focused on 478 vertigo/dizziness outpatients between March 1, 2019, and May 31, 2019, prior to the
COVID-19 pandemic, to compare the number of cancellations
between these 2 periods. Patients who had already been diagnosed with a disorder resulting in vertigo/dizziness and were
scheduled to attend follow-ups during the above study periods
were enrolled. Patients attending for an initial assessment were
excluded. ‘‘Cancellation’’ in the present study indicates that a
patient with a prior diagnosis who had made a reservation for
their next ENT visit to the hospital chose to cancel that reservation. ‘‘Non-cancellation’’ meant that a patient with a prior
diagnosis who had made a reservation for their next ENT visit
to the hospital attended that reservation.
In accordance with the diagnostic guidelines of the International Classification of Vestibular Disorders 2015, all the
enrolled patients were definitively diagnosed with benign paroxysmal positional vertigo (BPPV), Meniere’s disease (MD),
vestibular neuritis (VN), sudden deafness with vertigo (SDV),
or orthostatic dysfunction (OD).12-16 If necessary, these patients
Ear, Nose & Throat Journal 100(2S)
received various kinds of vertigo/dizziness examinations,
including the caloric test, vestibular evoked cervical myogenic
potentials, subjective visual vertical assessment, inner ear magnetic resonance imaging, the Schellong test, and self-rating questionnaires for depression as described previously.17,18 After
careful interviewing and examinations, patients with dizziness
of unknown origin were classified into unknown (UK).
Questionnaires
During the study period between March 1, 2020, and May 31,
2020, the telephone reservation center at the Nara Medical
University called all patients to determine their cancellation
or noncancellation intentions as a result of the COVID-19 situation in the Nara Prefecture. This system was not enforced by
law but had been recommended as an aid to patients to help
them make decisions regarding attendance during that period.
After the Japanese government ended the emergency
declaration in June 2020, the reasons for cancellation (Table
1A) and noncancellation (Table 1B) were investigated by
means of telephone multiple-choice questionnaires (telMCQs),
especially in patients with BPPV and MD at the ENT department. Among the diseases that cause vertigo/dizziness, BPPV,
and MD are the most common ailments. Benign paroxysmal
positional vertigo does not show progressive or irreversible
symptoms, while MD can cause recurrent vertigo attacks and
fluctuating/progressive sensorineural hearing loss.
The telMCQs addressed the reasons for cancellation or for
noncancellation. For both, the questions asked were concerned
with the current COVID-19 pandemic (questions a-1,2,3) and
their vertigo/dizziness symptoms (questions b-1,2,3). Each
cancellation or noncancellation for a patient with either BPPV
or MD was picked up randomly from the smaller medical
record number until 20 cases were collected.
Statistical Analyses
Chi-square tests were used to determine significant differences
between the outpatients’ backgrounds during the 2019 and
2020 study periods. The Kruskal-Wallis and paired t tests were
performed to examine significant differences between
the changes in the percent reduction in clinic attendance in
2020 compared to the same period during the previous year
(ie, [2019-2020]/2019) for various types of vertigo/dizziness
diseases. All reported P values were 2-sided, and those under
0.05 were considered significant. All statistical analyses were
performed using SPSS version 18.0 (SPSS Inc).
Results
Of the 478 vertigo/dizziness outpatients between March 1, 2019,
and May 31, 2019, 210 (43.9%) had BPPV, 143 (29.9%) had
MD, 34 (7.1%) had VN, 20 (4.2%) had SDV, 14 (2.9%) had OD,
44 (9.3%) had others, and 13 (2.7%) were UK (Figure 1A). Of
the 265 vertigo/dizziness outpatients between March 1, 2020,
and May 31, 2020, 76 (28.7%) had BPPV, 121 (45.7%) had MD,
Ueda et al
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Figure 1. The ratios of vertigo/dizziness outpatients with benign paroxysmal positional vertigo (BPPV), Meniere’s disease (MD), vestibular
neuritis (VN), sudden deafness with vertigo (SDV), orthostatic dysfunction (OD), others, and unknown (UK) cause at the ear, nose, and throat
(ENT) department in 2019 (nonpandemic) and in 2020 (COVID-19 pandemic). (A) The disease percentages for 478 vertigo/dizziness outpatients
between March 1, 2019, and May 31, 2019. (B) The disease percentages for 265 vertigo/dizziness outpatients between March 1, 2020, and May
31, 2020.
Figure 2. The percent reduction in clinic attendance for different vertigo/dizziness diseases from 2019 (nonpandemic) to 2020 (COVID-19
pandemic). Percent reduction in clinic attendance for different vertigo/dizziness diseases from 2019 to 2020 ([2019-2020]/2019) were as
follows: BPPV ([210-76]/210: 63.8%), MD ([143-121]/143: 15.4%), VN ([34-22]/34: 35.3%), SDV ([20-13]/20: 35.0%), OD ([14-7]/14: 50.0%),
others ([44-20]/44: 54.5%), and UK ([13-6]/13: 53.8%). BPPV indicates benign paroxysmal positional vertigo; MD, Meniere’s disease; OD,
orthostatic dysfunction; SDV, sudden deafness with vertigo; UK, patients with dizziness of an unknown origin were classified as unknown; VN,
vestibular neuritis.
22 (8.3%) had VN, 13 (4.9%) had SDV, 7 (2.6%) had OD,
20 (7.5%) had others, and 6 (2.3%) were UK (Figure 1B). The
total number of vertigo/dizziness outpatients decreased by
44.6% in the 2020 period compared to the same period in
2019. The percent reduction in clinic attendance from 2019 to
2020 due to cancellation was as follows: BPPV ([210-76]/210:
63.8%), MD ([143-121]/143: 15.4%), VN ([34-22]/34: 35.3%),
SDV ([20-13]/20: 35.0%), OD ([14-7]/14: 50.0%), others
([44-20]/44: 54.5%), and UK ([13-6]/13: 53.8%).
The percent reduction in clinic attendance for patients with
BPPV was higher than for those with MD. Compared to the
other vertigo-associated conditions, patients with MD exhibited a lower percent reduction in clinic attendance from 2019 to
2020 (Figure 2).
With regard to the telMCQs, no patients with BPPV or MD
cancelled because of (a-1) a fever higher than 37.5 C (99.5 F)
and/or because they had contracted COVID-19 within one week
before they were meant to attend the hospital. The reasons for
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Ear, Nose & Throat Journal 100(2S)
Figure 3. Results of the telephone multiple-choice questionnaires (telMCQs) regarding the reason for cancellation or noncancellation in
patients with benign paroxysmal positional vertigo (BPPV) or Meniere’s disease (MD). (A) There were no patients with BPPV or MD belonging
to a-1 in the present study. The reasons for cancellation for BPPV patients were as follows: n ¼ 2 for a-2-b-1, n ¼ 10 for a-2-b-2, n ¼ 4 for
a-2-b-3, n ¼ 0 for a-3-b-1, n ¼ 1 for a-3-b-2, and n ¼ 3 for a-3-b-3. The reasons patients with MD cancelled were as follows: n ¼ 6 for a-2-b-1,
n ¼ 9 for a-2-b-2, n ¼ 2 for a-2-b-3, n ¼ 0 for a-3-b-1, n ¼ 1 for a-3-b-2, and n ¼ 2 for a-3-b-3. (B) There were no patients with BPPV or MD
belonging to a-1 in the present study. The reasons for noncancellation for patients with BPPV were as follows: n ¼ 12 for a-2-b-1, n ¼ 4 for
a-2-b-2, n ¼ 0 for a-2-b-3, n ¼ 1 for a-3-b-1, n ¼ 3 for a-3-b-2, and n ¼ 0 for a-3-b-3. The reasons those with MD did not cancel were as follows:
n ¼ 3 for a-2-b-1, n ¼ 10 for a-2-b-2, n ¼ 2 for a-2-b-3, n ¼ 2 for a-3-b-1, n ¼ 2 for a-3-b-2, and n ¼ 1 for a-3-b-3. There were no patients with
BPPV or MD who had a fever higher than 37.5 C (99.5 F) and/or contracted COVID-19 within one week before they were meant to attend the
hospital, an answer of a-1. The telMCQs revealed that 64 (80.0%) of 80 participants felt anxious about COVID-19 infection at their visit. A total
of 12 (75.0%) of 16 BPPV patients and 15 (88.2%) of 17 MD patients with mild to severe symptoms gave up their reservation due to fear of
COVID-19 infection. On the other hand, 4 (25.0%) of 16 BPPV patients and 12 (80.0%) of 15 MD patients with slight to moderate symptoms
completed their medical examination despite fear of COVID-19 infection. ‘‘Cancellation’’ in the present study meant that a patient who already
had a diagnosis and had made a reservation for their next ear, nose, and throat (ENT) visit to the hospital chose to cancel that reservation.
‘‘Non-cancellation’’ meant that a patient who already had a diagnosis and had made a reservation for their next ENT visit to the hospital chose to
attend that reservation. Please see Table 1 for details of the telMCQs questions asked.
cancellation for patients with BPPV (n ¼ 20) were as follows:
n ¼ 2 for a-2-b-1, n ¼ 10 for a-2-b-2, n ¼ 4 for a-2-b-3, n ¼ 0 for
a-3-b-1, n ¼ 1 for a-3-b-2, and n ¼ 3 for a-3-b-3. Those with MD
(n ¼ 20) cancelled for the following reasons: n ¼ 6 for a-2-b-1,
n ¼ 9 for a-2-b-2, n ¼ 2 for a-2-b-3, n ¼ 0 for a-3-b-1, n ¼ 1 for
a-3-b-2, and n ¼ 2 for a-3-b-3 (Figure 3A). The reasons for noncancellation for patients with BPPV (n ¼ 20) were as follows:
n ¼ 12 for a-2-b-1, n ¼ 4 for a-2-b-2, n ¼ 0 for a-2-b-3, n ¼ 1 for
a-3-b-1, n ¼ 3 for a-3-b-2, and n ¼ 0 for a-3-b-3. The reasons those
with MD (n ¼ 20) did not cancel were as follows: n ¼ 3 for
a-2-b-1, n ¼ 10 for a-2-b-2, n ¼ 2 for a-2-b-3, n ¼ 2 for
a-3-b-1, n ¼ 2 for a-3-b-2, and n ¼ 1 for a-3-b-3 (Figure 3B).
The telMCQs revealed that 64 (80.0%) of 80 participants
felt anxious about COVID-19 infection at their visit. A total of
12 (75.0%) of 16 BPPV patients and 15 (88.2%) of 17 MD
patients with moderate to severe symptoms cancelled their
reservation due to fear of COVID-19 infection. On the other
hand, 4 (25.0%) of 16 BPPV patients and 12 (80.0%) of 15 MD
patients with slight to moderate symptoms completed their
medical examination despite fear of COVID-19 infection.
Discussion
The Nara Medical University is situated within the Nara
Prefecture. The first Japanese patient to test positive for
COVID-19 was a tour bus driver in Nara Prefecture and is
believed to have contracted the virus after direct contact with
Chinese tourists during the bus tour in Japan. The Nara Prefecture is next to the Osaka Prefecture, one of the biggest cities
in Japan, with many COVID-19 positive patients thereafter.
Therefore, outpatients who visit university hospitals may fear
Ueda et al
contracting the COVID-19 infection while traveling from their
home to the hospital and vice versa.
Among the diseases that cause vertigo/dizziness, BPPV
does not show progressive or irreversible symptoms. Most of
the outpatients that cancelled during the COVID-19 pandemic
had BPPV. This might be a reasonable reaction because BPPV
is the most common cause of vertigo, with a lifetime prevalence of 2.4%.19 The vertigo and dizziness symptoms associated with BPPV is considered to result from debris that is
composed of small calcium crystals from the utricle that are
stuck to the crista ampullaris20 and/or floating in the ear
canal.21 BPPV is usually self-limiting. For the posterior semicircular canal type of BPPV, symptoms generally subside or
disappear approximately 1 month after onset, and within
2 weeks of onset in the horizontal semicircular canal type of
BPPV.22 MD can cause recurrent vertigo attacks and fluctuating/progressive sensorineural hearing loss. Outpatients with
MD had the least number of cancellations during the
COVID-19 pandemic. This is also a reasonable reaction,
because MD is characterized by recurrent vertigo attacks, fluctuating hearing loss, and tinnitus, which is a common disease
with an incidence of 15 to 50 people per 100 000.23 Some
patients with MD are prevented from participating in activities
of daily life, including interaction with their social environment, work, and schooling, due to frequent attacks of vertigo,
especially with progressive sensorineural hearing loss, in spite
of various kinds of medication. This type of MD is generally
called intractable and sometimes requires surgical
intervention.24,25
According to the results of the telMCQs, 75.0% of BPPV
cases and 88.2% of MD cases cancelled their appointment and
avoided visiting hospitals due to fear of COVID-19 infection,
even if they still had moderate to severe symptoms. It is problematic that patients who needed appropriate treatment gave
up their appointments due to fear of COVID-19 infection. On
the contrary, 25.0% of BPPV cases and 80.0% of MD cases that
did not cancel their appointment should not have visited the
hospital but stayed home because of their slight symptoms. It is
also problematic that patients who do not need to visit the
hospital, do so because they are worried about their health.
Both visiting hospitals and not visiting hospitals during the
COVID-19 pandemic could be stressful for patients, especially
those with vertigo/dizziness, and this kind of stress might negatively influence their symptoms.26,27
This study has 2 limitations. Firstly, the dramatic reduction
in the number of outpatients at the ENT department of the Nara
university hospital during the 2020 pandemic was compared to
the same period in 2019. In our medical records, the total
number of vertigo/dizziness patients and the variants of vertigo/dizziness diseases were constant during the most recent
3 years, 2017 to 2019. Therefore, it was only possible to discuss
the number of outpatients between 2019 and 2020. Secondly,
the severity of vertigo/dizziness in the patients with BPPV and
MD was not determined by the relevant guidelines but by the
patients’ subjective complaints. However, it is possible that
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conclusions derived from patients’ subjective data will become
part of advanced medical care in the future.
Conclusion
Under the current COVID-19 circumstances, remote medicine
is considered a suitable alternative to face-to-face appointments across many medicine-related fields worldwide. Remote
medicine also called telehealth, online care, and web-based
connected care, began to rapidly play an active part in the
medical care system once the pandemic began.28-30 The WHO
also recommends the use of information and communication
technology to maintain and improve health, so-called
e-Health.31 In the ENT field related to vertigo/dizziness, online
medicine may include video-lectured diagnosis and canalith
repositioning treatment for BPPV,32 stress less life guidance
for MD, and vestibular rehabilitation for VN and SDV. After
the COVID-19 pandemic ends, it will be time to prepare for an
advanced way of providing medical care, not only for the disease itself but also for the mental distress behind persistent
symptoms.
Acknowledgments
The authors wish to thank Dr Masashi Choubi, a registered statistician
(certificate number: 622017) for the helpful advice on the statistical
analyses and Editage Customer Service (editage.com) for editing the
draft of this manuscript.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article: This study
was supported in part by a Japan Society for the Promotion of Science
KAKENHI Grant (2020-2022), the Japan Agency for Medical
Research and Development (Grant Number 18dk0310092h000a), and
a Health and Labour Sciences Research Grant for Research on Rare
and Intractable Diseases (R02-Nanchito (Nan)-Ippan-04) from the
Ministry of Health, Labour and Welfare of Japan [grant number
R02-Nanchito (Nan)-Ippan-04].
ORCID iD
Tadashi Kitahara
https://orcid.org/0000-0001-9598-6287
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