A FEW WORDS... Head tilt & loss of balance (from Ep 3)

Client communication tips:

A lot of the win here is how you frame it:

What owners think: “Neuro signs” → “stroke” → “brain tumour” → “put to sleep today”.

What you can say early (when appropriate):

“This can look terrifying, but it's usually a balance problem rather than a stroke, and a lot of these cases improve quickly.”

“Let’s check for the red flags that would make us worry about brain involvement.”

“If it’s the common ‘old dog vestibular’ pattern, we treat the nausea and support them, and you should see a huge improvement over the next couple of days.”

Then be honest:

If very severe, head tilt can linger a little.

relapses can happen, but rarely more than once or twice, often months apart in my experience.

If deterioration occurs, you need to reassess promptly..

History

Head tilt. Nystagmus. Ataxia. Maybe vomiting. Peracute onset.

Good news: a lot of these cases are surprisingly kind to us - if you can (1) keep everyone calm, (2) take a decent history, and (3) do a “good-enough” neuro exam that helps you decide peripheral vs central vestibular. Most patients can go home with good nursing advice and anti-nausea meds.

History: the 2-minute “don’t miss the obvious” checklist

Before you disappear into the neuro abyss, grab the key stuff:

1) Ears, ears, ears

Ask about any ear/skin history:

chronic otitis externa (infection in the ear canal), “allergies”, paw chewing, head shaking, discharge, long-standing subtle head tilt the owner didn’t notice.

The reason we are trying to identify if there is a history of ear disease is if otitis externa ruptures through the tympanum (ear drum), the resulting otitis media (middle ear infection) will typically result in a head tilt. And this otitis media can be a precursor to otitis interna (inner ear infection) -and that's when the balance loss occurs.

Also worth remembering: middle/inner ear disease isn’t always from otitis externa — infection can potentially spread via the Eustachian tube or haematogenous routes (rare, but it stops you being falsely reassured by a clean-looking external ear).

2) Toxicology

Always ask the owner about this possibility. Not usually top of the list in “classic vestibular”, but easy to miss and often self resolving and transient.

3) Medications

The big one: metronidazole (especially higher dose / longer courses).

Also ask about recent ear drops (ototoxicity risk if tympanum compromised).

4) Timeline + progression

This is huge:

peracute onset + stabilising/improving over 24–72h fits idiopathic vestibular

Does this look peripheral vestibular… or central vestibular?

Here’s a very GP-friendly framework.

“5 bits” that help you localise:

1. Assess mentation

2. Assess ataxia. Falling? Always the same way?

3. Postural reactions / proprioception. Simple paw placement/turning is often enough in GP. (If you can do hops/hemi-walk—great. If not—don’t beat yourself up.)

4. Limb strength. True weakness makes you worry about central disease. I check this by assessing gait. You're looking for paresis.

5. Cranial nerve exam - see our basic checks later.

Central vestibular red flags (the “please don’t just send home” list):

• Abnormal mentation: (this is a biggie). Sniffing, engaged, interactive = reassuring. Feels more peripheral. Dull/obtunded = not reassuring. More likely central.

• True limb weakness

• Vertical nystagmus OR nystagmus that changes direction with head position

• Proprioceptive deficits (paw placement/hopping clearly abnormal)

• Other cranial nerve deficits. Though, to make life difficult, Brendan has seen two cases of peripheral vestibular disease that resolved but had concurrent facial nerve deficits. Concurrent Horner's syndrome can also occur.

The dreaded cranial nerves exam…

If cranial nerves make you want to fake a phone call, try Brendan’s “treat-based neuro exam”:

CN I (olfactory): sniffing a treat (rough and ready)

CN II (optic): navigating, tracking movement, menace. I find it easiest just to dart my hand to the side whilst in front of the patient and see if they track my hand. I often do this whilst taking the history, which probably amused my clients. Problematic if the patient has bilateral cataracts by the way!

CN III/IV/VI: eye position at rest + normal movement of the eye when moving their head? Don't over think it. A strabismus is often quite noticeable if present.

CN V (trigeminal): facial sensation + jaw tone/masticatory muscle bulk. Find a blunt metal instrument, test sensation in the ear canal, near the eye and lower down the face.

CN VII (facial): facial droop, are the eyelids more closed on one side making the eyeballs look different sizes? Lip droop resulting in drooling on one side can be very obvious. Don't confuse with nausea!

CN VIII: hearing response (just clap, even at a normal loudness as most dogs will lift their ears for a split second).

CN IX/X/XII (and friends): can they prehend/chew/swallow the treat?

Not perfect. But wildly better than panicking. Is there tongue sitting correctly in their mouth?

Differentials: what’s actually likely?

Peripheral causes (much more common)

1) Idiopathic vestibular disease (aka “geriatric vestibular”)

Classic: older dog (often 12+years old), look out for the peracute onset, dramatic signs, but normal mentation. Most show big improvement, sometimes within hours (infrequently head tilt may linger or persist).

Anti-nausea meds matter: vestibular dogs are often properly nauseous, not just “a bit dizzy”. There’s evidence ondansetron improves nausea associated with acute vestibular syndrome.

2) Otitis media/interna

Often history of chronic otitis externa, sometimes ruptured tympanum. Middle ear involvement may present with a head tilt. However, loss of balance will only occur once the problem is in the inner ear.

Plain rads can hint (bulla opacity / sclerosis) but CT is best when you need certainty.

3) Ototoxicity

Usually ear drops + compromised tympanum. Can improve with time + stopping/flush-out (when appropriate).

4) Masses/polyps

E.g. inflammatory polyps, middle ear neoplasia.

Central causes (where your stress levels rise)

MUO / inflammatory brain disease

intracranial neoplasia

infarcts (“stroke-like” events)

metronidazole toxicity

Treatment

“So… what do we do as a GP?”

For the classic older dog who looks peripheral, a very defensible plan looks like this:

• antiemetic (maropitant or ondansetron)

• strict calm: dimly lit room, non-slip flooring, minimal stimulation

• nursing advice: sling support, block stairs, assist feeding/water

• consider basic bloods ± BP (if you suspect systemic contributors / infarct risk, or if the owner wants a “we checked something” reassurance)

• recheck in a few days

  
  

When should you refer?

Clear safety-netting: “should not worsen; should start improving”. If they’re not improving, not eating, getting dull, or showing any central flags: rethink + escalate.

When you should strongly consider referral (or at least have the honest chat):

• any central vestibular red flags

• progressive deterioration

• pain symptoms

• young animal with vestibular signs

• persistent signs that aren’t following the expected “getting better” story

And yes — sometimes the consult is really about the owner’s limits (finances, travel, age/comorbidities). That’s real life.

An important spanner (because neuro loves chaos)

Bilateral idiopathic vestibular disease (the “why no head tilt?” one)

Brendan’s experience: from my first-opinion caseload, this is much more common than has been reported.

Clues:

• sudden, peracute onset in an older dog

• minimal/absent head tilt

• often no obvious nystagmus, or transient nystagmus.

• crouched, wide-based stance, swaying “sailor” gait

• mentation still normal

  
  

These can be mistaken for toxicity because they don’t read as classic unilateral vestibular.

Cats and vestibular symptoms

In 25 years, I've only had a couple of feline cases with suspected peripheral vestibular syndrome and they both took much longer than a dog would take to improve. They are reported to occur seasonally, with groups of cases reported.

Cats with vestibular signs are less common, so when they do show up, think more about:

• polyps / ear disease (and secondary otitis interna)

• trauma

• neoplasia

• central causes when red flags present

(If anyone has loads of feline idiopathic vestibular in the wild — tell us, because we barely see it.)

Rabbits:

Head tilt turned up to 11. Rabbits don’t do a gentle 20-degree tilt. They go full Picasso.

Common suspects in practice:

E. cuniculi

otitis media/interna (e.g. Pasteurella and friends)

A UK retrospective study of 73 pet rabbits found otitis media/interna and encephalitozoonosis were the most common causes of head tilt, and suggested paired E. cuniculi serology + CT head as baseline investigations.

Realistically, many GP cases don’t get CT + paired titres, so treatment often looks like:

• analgesia/anti-inflammatory (meloxicam commonly used; the study noted an association with favourable outcome)

• antiparasitic (fenbendazole/Panacur where EC suspected)

• antibiotics (a rabbit-safe one please)

• intensive nursing/feeding support. Use rolls of bedding to prevent rolling. Ensure food and water requirements are met.

  
  

Prognosis in the real world: often surprisingly decent with committed nursing — but residual head tilt without balance loss is common even when they stabilise. Many rabbits continue to eat despite the loss of balance.

The weird rabbit bonus: “Epley manoeuvre… for bunnies?”

There are anecdotal reports of head-position manoeuvres (see YouTube for Epley manoeuvres in people) improving some rabbits with rolling/head tilt - sometimes dramatically so!

Neither Charlotte or I have tried it yet, so please have a try and tell us if it helped or didn't!

References:

Bradshaw, J.M., Pearson, G.R. and Gruffydd-Jones, T.J. (2004) ‘Feline idiopathic vestibular syndrome: clinical features and outcome’, Journal of Feline Medicine and Surgery, 6(2), pp. 87–93.

Cole, L.K., Kwochka, K.W., Kowalski, J.J. and Hillier, A. (2004) ‘Otitis media and interna in dogs and cats’, Veterinary Clinics of North America: Small Animal Practice, 34(2), pp. 455–468.

De Matos, R., et al. (2015) ‘Computed tomographic features of otitis media and interna in rabbits’, Journal of the American Veterinary Medical Association, 246(3), pp. 336–342.

Dewey, C.W. and da Costa, R.C. (2016) Practical Guide to Canine and Feline Neurology. 3rd edn. Hoboken, NJ: Wiley Blackwell.

Evans, J., Levesque, D., Knowles, K., Longshore, R. and Platt, S.R. (2003) ‘Metronidazole toxicosis in dogs: neurologic signs and MRI findings’, Journal of Veterinary Internal Medicine, 17(3), pp. 304–310.

Garosi, L.S., McConnell, J.F., Platt, S.R. and Barone, G. (2005) ‘Clinical and magnetic resonance imaging features of suspected cerebrovascular disease in dogs’, Journal of Veterinary Internal Medicine, 19(4), pp. 488–495.

Garosi, L.S., Lowrie, M., Swinbourne, F. and Dennis, R. (2001) ‘Idiopathic vestibular syndrome in dogs: clinical features and outcome’, Journal of Small Animal Practice, 42(6), pp. 279–284.

Garosi, L. (2012) ‘Vestibular syndrome in cats’, Journal of Feline Medicine and Surgery, 14(6), pp. 381–392.

Harcourt-Brown, F. (2013) Textbook of Rabbit Medicine. 2nd edn. Oxford: Butterworth-Heinemann.

Kent, M., Platt, S.R., Schatzberg, S.J. and Theoret, C. (2015) ‘Ondansetron use in dogs with vestibular disease and nausea’, Journal of Veterinary Emergency and Critical Care, 25(3), pp. 371–377.

Liatis, T., Makri, N., Czopowicz, M., Richardson, J., Nuttall, T. and Suñol, A. (2024) ‘Otitis media/interna and encephalitozoonosis are the most common causes of head tilt in pet rabbits in the UK: 73 cases (2009–2020)’, Veterinary Record, 195, e4267. https://doi.org/10.1002/vetr.4267⁠�

Lowrie, M., Garosi, L., McConnell, J.F. and Dennis, R. (2011) ‘Magnetic resonance imaging characteristics of presumed cerebrovascular accidents in dogs’, Veterinary Radiology & Ultrasound, 52(4), pp. 424–432.

Papich, M.G. (2020) Saunders Handbook of Veterinary Drugs. 5th edn. St Louis, MO: Elsevier.

Platt, S.R. and Olby, N.J. (2013) BSAVA Manual of Canine and Feline Neurology. 4th edn. Gloucester: British Small Animal Veterinary Association.

Rossmeisl, J.H. (2010) ‘Vestibular disease in dogs and cats’, Veterinary Clinics of North America: Small Animal Practice, 40(1), pp. 81–100.

Snell, J., et al. (2015) ‘Computed tomography findings in canine otitis media’, Veterinary Radiology & Ultrasound, 56(3), pp. 339–344.

Tauro, A., et al. (2018) ‘Magnetic resonance imaging features of metronidazole neurotoxicity in dogs’, Veterinary Radiology & Ultrasound, 59(6), pp. 693–701.

Disclaimer

The content in this blog post is for veterinary professionals and is for general information only. It does not replace clinical judgement or case-specific decision-making. Always check current product datasheets, dosing references, and your local protocols, and escalate/referral when red flags or deterioration occur.