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VESTIBULAR DISEASE
Jared B. Galle, DVM, Diplomate ACVIM (Neurology)
Dogwood Veterinary Referral Center
4920 Ann Arbor-Saline Road
Ann Arbor, MI 48103
Introduction
The vestibular system is essential in maintaining balance and preventing an animal from falling
over. Head tilt, falling, rolling, leaning, circling, nystagmus, and ataxia are common signs of a
problem in the vestibular system. Clinical signs of vestibular disease may result from a lesion
involving the peripheral vestibular components (receptors in the inner ear or vestibular portion of
cranial nerve 8) or the central vestibular components (brainstem vestibular nuclei or vestibular
centers in the cerebellum). Knowing the neurologic signs that result from a lesion in each
component is important in determining potential causes and what diagnostics to perform. This
lecture will review the clinical approach to a patient with vestibular disease.
1. What are the most common signs of vestibular disease?
Vestibular diseases are common in dogs and cats and may result in any combination of the
following clinical signs: head tilt, falling, leaning, rolling, circling, nystagmus, strabismus, and
ataxia. Vomiting can also be seen with acute vestibular disorders.
Head Tilt: A head tilt commonly occurs with vestibular disease and is usually towards
the side of the problem. It is an abnormal head posture characterized by a rotation of
the head due to a loss of antigravity muscle tone on one side of the neck. A head tilt
must be differentiated from a head turn (torticollis) in where the median plane of the
head remains perpendicular to the ground, but the nose is turned to one side. A head
turn is not associated with a vestibular disorder but can occur with forebrain and
brainstem diseases.
Circling: Can occur with either a vestibular disease or with a focal forebrain disease.
Animals usually circle toward the side of the problem. Tight circles are usually seen
with vestibular diseases, while wide circles (almost pacing) are often associated with
forebrain diseases.
Nystagmus: This is involuntary, rhythmic oscillations of the eyeballs. There are two
types of nystagmus - physiologic and pathologic. Physiologic nystagmus occurs in
normal animals while pathologic nystagmus occurs with vestibular disease.
Physiologic nystagmus can be induced in a normal animal by turning the head side to
side (also know as the vestibulo-ocular reflex). It is characterized by a slow phase in
the opposite direction of the head movement and a fast phase (compensatory phase) in
the same direction of the head movement. The direction of the nystagmus is defined in
the direction of the fast phase which is typically away from the side of the problem.
Physiologic nystagmus can be decreased or absent in animals with vestibular disorders.
Pathologic nystagmus occurs with vestibular disease and can be either spontaneous or
important features of CVD are vertical nystagmus and positional nystagmus (nystagmus that
changes direction on changing head position). The presence of cranial nerve deficits other than
facial (7) or vestibulocochlear (8) is suggestive of a central lesion. Alterations of consciousness
of mental status may also support a CVD.
The following table can be used to help differentiate a PVD versus CVD based on the clinical
signs.
PVD
CVD
Head tilt
Yes (ipsilateral)
Ataxia
Yes (ipsilateral)
Yes (ipsilateral)
Nystagmus
Horizontal
Rotary
Vertical
Positional
Yes
Yes
NO
Rarely
Yes
Yes
YES
Yes
NO
YES (ipsilateral)
Circling
Yes (ipsilateral)
Facial paralysis
YES (ipsilateral)
Uncommon
Horners syndrome
YES (ipsilateral)
Uncommon
Once a lesion has been localized to the peripheral or central vestibular component on one side of
the body, a differential list and necessary diagnostics can be determined.
3. What is Paradoxical Vestibular Disease?
Paradoxical Vestibular Disease is a specific CVD that occurs with a lesion in the caudal
cerebellar peduncles or flocculonodular lobes of the cerebellum, which results in a head tilt that
is away from the side with the lesion. The patient may also circle away from the side with the
lesion. Another unique feature of this disease is the fast phase of the nystagmus will be towards
the side with the lesion. The key to localizing which side of the cerebellum has a lesion is to
determine which side has proprioceptive deficits. The postural reaction deficits will be on the
same side as the lesion, while the head tilt will be in the opposite direction. The most common
causes of Paradoxical Vestibular Disease include a tumor, an infarction, and an inflammatory
disease.
persisting. Dogs with CVD may not respond as well depending on the presence of a brain
infarction.
5. What are the most common central vestibular diseases?
The most common CVDs include encephalitis, brain tumors, vascular infarctions, and
metronidazole toxicity.
Encephalitis is probably the most common cause of CVD. Although encephalitis can occur in
any breed, it occurs most commonly in young to middle-aged, small breed dogs. Autoimmune
diseases (GME, necrotizing encephalitis) and infectious diseases (distemper, RMSF, E. canis,
FIP, Toxoplasmosis) are the main causes of encephalitis. A diagnosis is based on the history,
signalment, clinical signs, MRI findings (multifocal contrast enhancing lesions), cerebrospinal
fluid analysis, and infectious disease titers. Autoimmune encephalitis is treated with
immunomodulatory drugs. Corticosteroids are traditionally given as the primary treatment;
however, other immunomodulatory drugs (azathioprine, cytosine arabinoside, cyclosporine)
which have traditionally been used as an add-on therapy to corticosteroids are starting to be used
more often as the primary treatment. The prognosis for autoimmune encephalitis is guarded as
animals may live weeks to years. Treatment for infectious encephalitis is based on the cause and
the prognosis varies.
Brain tumors in the caudal fossa are a common cause of CVD in dogs older than 5 years of age.
Tumors in this location affect the vestibular nuclei in the brainstem and the vestibular portions of
the cerebellum. Meningiomas and choroid plexus tumors are the most common tumors that
occur in the caudal fossa. Clinical signs are often slowly progressive. A presumptive diagnosis
is made by advanced imaging (CT or MRI) and is confirmed with histopathology. Treatment and
prognosis depend on the location and tumor type. Surgical approaches to the caudal fossa can be
difficult and may limit surgery as a treatment option. Radiation therapy may be used to treat
primary intracranial tumors when surgery is not a treatment option. The median survival times
vary with treatment, tumor type and location.
Vascular infarctions can occur in the brainstem or cerebellum resulting in CVD, although they
are more likely to occur in the cerebellum. They are more common in dogs than cats.
Neurologic signs are acute and nonprogressive. MRI and spinal fluid analysis are needed to
exclude other CVDs and make a presumptive diagnosis. There is no definitive treatment;
however, animals usually improve within 5-7 days and may completely recover. Further
evaluation for renal disease, hyperadrenocorticism, hypothyroidism, hypertension,
pheochromocytoma, and diseases that may predispose for vasculitis and thrombosis should be
considered.
Metronidazole is commonly used to treat a variety of conditions in dogs and cats. CVD has been
reported to occur in animals taking dosages >60 mg/kg/day for 7-12 days but signs can occur in
animals taking lower dosages. A presumptive diagnosis is based upon neurologic signs and a
history of metronidazole administration. Clinical signs usually resolve 1-2 weeks after
discontinuing the drug. Diazepam administration in dogs can shorten the recovery time to 3 days
(0.43 mg/kg orally or IV every 8 hours for 3 days).
Vestibular Diseases
Disease
PVD
CVD
Degenerative
Uncommon
Uncommon
Anomalous
Congenital
Metabolic
Hypothyroidism
Hypothyroidism (rare)
Neoplastic
Nutritional
Thiamine deficiency
Inflammatory/Infectious
Otitis media/interna
Nasopharyngeal polyp
Idiopathic
Toxic
Aminoglycoside antibiotics
Chlorhexidene flush
Iodophors flush
Metronidazole
Trauma
Head trauma
Head trauma
Vascular
Infarction
Hemorrhage
6. What tests can be done in a general practice for a patient that has vestibular disease?
The minimum data base for all patients with vestibular signs should include a complete blood
count, biochemistry profile, thyroid testing, urinalysis, otoscopic exam, and pharyngeal exam.
Peripheral Vestibular Disease
The diagnostic plan for patients with PVD includes a thorough otoscopic exam and imaging of
the tympanic bulla radiographs. These tests should be done under sedation or general anesthesia.
A thorough examination of the external ear canal can be performed with a hand-held otoscope or
video-otoscopy. Middle ear pathology should be suspected if the tympanic membrane is
ruptured, bulging, or cloudy. While diseases affecting the external canal may be visualized, the
presence of an intact tympanic membrane does not eliminate the possibility of a middle ear
disease. If the tympanic membrane is ruptured, a culture can be taken from the middle ear
cavity. If the tympanic membrane is intact, a myringotomy can be performed to obtain a culture.
Radiographs of the tympanic bulla require general anesthesia to allow for adequate positioning.
Five conventional radiographic views are needed to investigate the osseous bulla: dorsoventral,
lateral, open-mouth, and a right and left 20 lateral oblique views. Although positive radiographs
can diagnose middle ear disease, negative radiographs do not rule out the presence of middle ear
disease. Radiographic evaluation of animals with vestibular disease is not typically performed
because of the complexity of the anatomy of the head, superimposition of structures, and the lack
of specificity associated with radiographic findings. Computed tomography and MRI are more
sensitive than radiographs in diagnosing middle ear disease.
Thoracic radiographic should be obtained in older animals to exclude systemic diseases that may
have spread to the nervous system (i.e. fungal disease or metastatic neoplasia). Similarly, in
animals exhibiting clinical signs referable to the abdominal cavity, radiographic or
ultrasonographic examination of the abdomen should be performed. Identifying an underlying
systemic disease through noninvasive imaging technique may provide a presumptive diagnosis
for vestibular dysfunction, thereby eliminating unnecessary risk to the animal and expense to
owners.
Central Vestibular Disease
In addition to the minimum database, the diagnostic workup for patients suspected of having
CVD includes advanced imaging (computed tomography or MRI), cerebrospinal fluid analysis
(CSF), and serum/CSF titers for various organisms.
Additional testing would be based on the presumptive diagnosis.
Brain tumor (biopsy, investigate for metastatic disease)
Cerebrovascular accident (clotting profile, blood pressure, cardiac evaluation, adrenal
testing)
7. When should I refer a patient with vestibular disease to a neurologist?
Any patient that has neurologic deficits consistent with CVD should be referred to a neurologist
for further evaluation. These include postural reaction deficits and vertical nystagmus. If either
of these are present, the patient should be referred. Patients with otitis media/interna that are not
responding to therapy should also be referred for further evaluation. Patients suspected of
having idiopathic disease that do not improve or develop other neurologic deficits should be
referred. Referral should also be recommended for any patient that has intermittent vestibular
signs.
8. What is the prognosis for vestibular disease?
The prognosis for vestibular disease depends on the cause. The one thing to stress to clients
when discussing prognosis is that regardless of the cause, the head tilt is often the last neurologic
sign to improve and is often permanent. This does not interfere with the animals quality of life
and is not debilitating.
9. I have a patient with CVD. The client doesnt have money for an MRI. What can I do?
When a client does not have money for diagnostics, empirical treatment for the most common
CVDs can be initiated. The minimum diagnostic database (bloodwork, thoracic radiographs,
urinalysis, complete thyroid panel) should be done prior to starting empirical treatment.
Empirical Treatment
Dose
Rationale
Prednisone
Inflammatory disease
Peritumoral edema
Clindamycin
Toxoplasmosis infection
Neosporosis infection
Doxycycline or
Minocycline
E. canis
RMSF
Meclizine
25 mg PO SID (dogs)
12.5 mg PO SID (cats)
Reduce nausea
Cerenia
Stop vomiting
10. Are there any drugs other than Meclizine (Antivert) that treat nausea?
Diphenhydramine (Benadryl) or Dimenhydrinate (Dramamine) can be used to help treat motion
sickness and nausea that can occur with vestibular disease. The exact mechanism of how these
drugs interact with the vestibular system and vomiting center is not known.
Drug
Dose
Diphenhydramine (Benadryl)
Dimenhydrinate (Dramamine)