The vestibular system is responsible for maintaining normal balance. The vestibular system has central components located in the brain, and peripheral components located in the inner and middle ear.
What is vestibular disease?
Vestibular disease refers to a sudden, non-progressive disturbance of balance. It is more common in older dogs. It is also referred to as old dog vestibular syndrome and canine idiopathic vestibular syndrome.
What are the clinical signs of vestibular disease?
Most dogs present with the sudden onset of loss of balance, disorientation, head tilt, and irregular jerking eye movements called nystagmus. Many dogs will become reluctant to stand or walk. Most dogs will lean or fall in the direction of their head tilt.
What causes vestibular disease?
Causes of vestibular disease include middle or inner ear infections, drugs that are toxic to the ear, trauma or injury, tumors, and hypothyroidism. When no specific cause is found, the condition is called idiopathic vestibular syndrome. These cases are distinguished by the sudden onset of clinical signs and the subsequent rapid improvement with little, if any, medical intervention.
How is vestibular disease diagnosed?
Diagnosis is based on medical history, clinical signs, and the results of blood and urine tests. In some cases, diagnostic testing might include blood pressure measurement, or radiographs (X-rays) of the head to assess the appearance of the middle and inner ears and the tympanic bullae. Occasionally, magnetic resonance imaging (MRI) or computed tomography (CT) scans will be performed to look for tumors or other abnormalities. Brainstem auditory evoked response (BAER) testing may also be performed in some patients.
The criteria for diagnosing canine idiopathic vestibular syndrome are:
- older dog
- sudden onset of peripheral vestibular signs
- no detectable cause (i.e., no signs of outer- or middle-ear infection, ototoxicity, trauma, hypothyroidism, infectious disease, etc.)
- signs resolve over several weeks
How is vestibular disease treated?
Treatment is directed at the underlying cause, if one can be identified. In severe cases, supportive therapy such as intravenous fluids and hospitalization may be required until the dog can eat and walk on its own. If the dog is seriously disoriented or ataxic (stumbling, unable to stand or walk), it may be given sedatives to help it relax. Drugs that help combat nausea or motion sickness may be beneficial. Antibiotics may be used in cases suspected of having middle or inner ear infections. Although corticosteroids have been used in the past, there is little scientific evidence to support their use in this condition and are generally not recommended.
What is the prognosis for a dog diagnosed with vestibular disease?
The clinical signs associated with vestibular disease are often most severe during the first twenty-four to forty-eight hours. Many pets begin to improve within seventy-two hours. The head tilt and stumbling often improve over a seven to ten-day period. Most patients are completely recovered within two to three weeks, although some will have residual symptoms such as a head tilt or mild "wobbling" for life.
If the patient fails to improve or worsens, then a more severe underlying disorder should be suspected, and advanced diagnostic testing should be pursued. A referral to a veterinary neurologist may be advised.
If your dog is staggering, stumbling, or falling over, it may be the result of a variety of medical issues, including injury, stroke, poisoning, or an infection. Here, our Matthews Emergency and Specialty Vets explain why you should get to a veterinary hospital right away.
Why is my dog staggering?
If you notice that your dog suddenly loses their sense of balance they could be suffering from any of the following health issues. Signs of loss of balance should not be ignored since they can indicate a serious medical emergency. If your dog shows signs of any of the following health issues it's time to head to the vet straight away.
Ataxia
Ataxia is a condition relating to sensory dysfunction that results in a loss of coordination in the rear end, head, or limbs. Three kinds of ataxia are commonly seen in dogs: vestibular, cerebellar, and sensory.
Vestibular ataxia is the result of an issue with the inner ear or brainstem. Cerebellar ataxia occurs when the cerebellum is damaged. Sensory ataxia is when the spinal cord becomes compressed due to a bulging intervertebral disk or a tumor.
As well as staggering, stumbling and falling over, signs of ataxia include flicking of the eyes from side to side, head tilt, walking in circles, vomiting, and nausea.
Ear Infection
Inner ear infections are a common cause of balance loss in dogs. If your dog has an ear infection, you may also notice additional symptoms like head shaking and scratching, walking in circles, and eye flicking, as well as redness, swelling, discharge, and odor in or around the affected ear.
Trauma/Injury
Head trauma, injury or damage to the inner ear can cause balance issues in dogs. It can be difficult to tell if a dog is injured because dogs tend to be very good at masking pain. Signs and symptoms of pain in dogs include heavy panting, slowed reflexes, change in appetite, enlarged pupils, biting or licking the wounded area, reluctance to lie down, and anxiety.
Stroke
Strokes in dogs are fairly uncommon, nonetheless, they can happen. A stroke can be the result of blood clots, high blood pressure, hemorrhage, head trauma, kidney disease, or migrating worms. Signs that your dog may be having a stroke include loss of balance, head tilt, circling, loss of vision, and collapse.
Brain Tumor
Sometimes brain tumors will occur in dogs, particularly senior dogs, and can lead to a general loss of balance, staggering, and stumbling. Other symptoms of a brain tumor depend upon the location of the tumor, and include changes in behavior and/or appetite, seizures, signs of pain, head tilt, swaying, a wide stance, lack of coordination, head tremors, pacing, and flicking of the eye.
Brain Inflammation
Encephalitis or inflammation of the brain, can cause dogs to stagger, stumble, or fall over. Brain inflammation can result from a number of issues including fungal infections, tick-borne diseases, and parasites. Other symptoms of encephalitis include depression and fever.
For advanced care in veterinary neurology, oncology, surgery, cardiology or internal medicine for your dog, ask your vet for a referral for your pet to see one of our veterinary specialists at Carolina Veterinary Specialists in Matthews. Contact us today for more information.
Updated April 13, 2021
Some dogs you never forget. They are the ones you know you failed. Like Holly.
She came to me late one night for vestibular disease. And she certainly had all the classic signs:
- a head tilted to one side
- loss of balance and inability to walk
- rapid eye flicking called nystagmus
- even nausea and vomiting
It had been happening for two years, on and off, and she needed more of her medication. Except she really needed a whole lot more than that.
The truth when I explained it was too much for the owner to take. She decided I must be wrong, and I never saw her again. As far as I know, Holly never received the treatment she needed.
To understand why, you need to know why vestibular disease happens.
The Causes Of Vestibular Disease
The vestibular system is the organ that manages things like balance, head position and posture. It has two parts: one in the middle and inner ear (peripheral), and another in the brain (central). Anything that damages these areas causes the signs of head tilt and loss of balance.
Here are some of the more commonly reported causes:
- Middle or inner ear infection
- Idiopathic Vestibular Syndrome
- Drugs or other toxicities
- Head trauma
- Hypothyroidism
- Meningoencephalitis (MUO)
- Tumours
- Cerebrovascular Disease (“stroke”)
So how common are these in everyday dogs? it’s very hard to tell, because most of the data we have comes from veterinary specialists who tend to see more of the rare things.
We looked at the 132 cases of head tilt from our own clinic over the last 15 years. Here’s what we found…
The Causes Of Head Tilt In Dogs
| Otitis externa | 42 |
| Vestibular Syndrome | 28 |
| Otitis media/interna | 17 |
| CNS Tumour | 7 |
| Neck Pain | 5 |
| Focal seizure | 4 |
| Other | 29 |
Notice that when you only look at the symptom of head tilt there are another three common causes: neck pain, focal seizure and otitis externa. Neck pain can cause a wry neck, or torticollis, just like people. Focal seizure is a poorly understood but mostly harmless episode. Otitis externa is an ear infection that doesn’t go through the ear drum. Read more about each at the links.
‘Other’ causes included no more than two of: stroke, shaker syndrome, hypothyroidism, MUO, toxicity, head trauma, labyrinthitis, low blood glucose and more that could not be classified. It’s important to note that some of these would also have been strokes and tumours if advanced imaging like MRI were available.
Now, finally we can get back to talking about the most common mistake, and Holly’s story.
Otitis Media vs Vestibular Syndrome
The dog at the start was thought to have idiopathic vestibular syndrome but really she had otitis media. It’s an easy mistake to make, but the results are devastating. One is a painless condition that resolves by itself, the other causes unremitting pain, and only gets worse.
Idiopathic vestibular syndrome generally affects dogs over 10 years of age, comes on suddenly, and usually starts improving within 3 to 4 days. By four weeks most dogs are back to normal except for a slight head tilt in some. It then does not occur again on the same side.
No treatments have been shown to help, although we often give sedatives or anxiety medications to control any distress. The cause is unknown.
Otitis media and otitis interna are ear infections on the other side of the eardrum. Most of the time they started on the outside and spread through a ruptured eardrum.
Middle ear infections cause their signs by direct damage to the vestibular apparatus. They also often damage the facial and sympathetic nerves which travel close by. Therefore, middle ear disease as well as causing balance disorders, often causes a dropped lip from facial paralysis and a half-closed eye with a dilated pupil from Horners syndrome.
Commonly affected breeds are:
- French bulldogs
- Cavalier King Charles spaniels
- Cocker spaniels
- West Highland white terriers
Which are all breeds known for getting ear infections.
Help! My Dog Has A Head Tilt
If your dog has a head tilt, it’s important to know how to tell the benign from the serious causes. Therefore, the first thing to do is get a check up with your vet.
A head tilt without vestibular signs is most often going to be caused by an external ear infection. It definitely needs treatment, but as long as this is done it’s a lot less serious.
A head tilt with vestibular signs will have the following breakdown according to our data*:
- 39% Idiopathic Vestibular Syndrome
- 24% Otitis media/ interna
- 10% Tumour
- 27% Other
Here are some clues that your dog does not have idiopathic vestibular syndrome:
- Smell or discharge from the ear
- Repeated episodes
- Any signs of nerve damage
- Gradual (not sudden) onset
Treatment Of Otitis Media
All this matters, because success rates with treatment of middle ear infections depend on how quickly you act.
I saw a case of otitis media just the other day (that’s why the numbers in the graphic and the table are different). I’m not at all worried about that dog. The symptoms had only been present for two days and the infection won’t have established itself yet.
He went on a combination of local treatments known to be safe when the eardrum is ruptured, plus systemic antibiotics. I’ll be amazed if he isn’t right as rain in a week or two.
The other side of the coin are dogs like Holly or Denver here. Dogs with long-standing middle or inner ear infections are usually incurable with medicines alone.
So if you’re interested, click here to read about the surgery that Holly needed, and Denver got. It made a world of difference to his quality of life.
* total number excludes otitis externa, neck pain, focal seizures and 10 cases classified in ‘other’ that had a head tilt only
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By Andrew Spanner BVSc(Hons) MVetStud, a vet in Adelaide, Australia. Meet his team here. The information provided here is not intended to be used as a substitute for going to the vet. If your pet is unwell, please seek veterinary attention.