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Head Tilt - Causes

BY Sandi Ackerman in consultation with Barbara Deeb, DVM, MS
One of the saddest sights is a bunny with a head tilt. Are we doing the right thing to keep him alive? Is he still happy? Will he ever be cured? These are just a few of the questions that we ask ourselves when we suddenly have a rabbit who has to deal with this problem.

Possible causes of Head Tilt (also known as torticollis or wry neck)
-middle inner ear infection (otitis media)
-stroke (cerebrovascular accidents or emboli)
-trauma (facial or head)
- Encephalitozoon cuniculi (E. cuniculi)
- cancer (neoplasia)
- cervical muscle contraction
- raccoon or skunk round worms (Baylissasscarissp)
- fungal infections
- intoxication

Lets discuss these one at a time, starting with the one thought to be most common:

Middle Ear Infection
A middle ear infection is caused by a bacteria that has usually started with an outer ear infection, remained untreated (unnoticed) and has gradually worked itís way into the middle ear. Bacteria which have been cultured from these middle ear infections are Staphylococcus sp, Bordetella bronchiseptica, Escherichia coli, Pseudomonass aeruginosa and Pasteurella multocida.
Treatment needs to be very aggressive and will likely be over a period of weeks or months.
A culture and sensitivity should be done if at all possible, in order to determine which antibiotics the bacteria are sensitive to (which antibiotic can kill the bacteria and therefore eliminate the infection). Since it is often difficult to access the bacteria in order to do the culture, many veterinarians will opt to treat with one of the antibiotics known to be the most successful in curing an inner ear infection, this would usually be Baytril, Chloramphenicol or Penicillin G procaine with benzathaine. There is frequently no improvement noticed until treatment has been in process for 4 weeks. After that approximate time, if there is no improvement the antibiotic should be changed.
When attempts to clear the infection with antibiotics appear to be failing, the veterinarian may suggest surgery to clean out the abscess and to be able to obtain a sample for a culture & sensitivity. Antibiotics would need to be withheld for a minimum of 3 days prior to this procedure. Some treatments will include leaving a drain in the surgery sight in an attempt to allow the abscess to drain, although the exudate (pus) that rabbits produce is frequently very thick and may not drain at all.
If the head tilt is extreme, a steroid may also be prescribed in an attempt to reduce the inflammation and therefore the head tilt. And, if the rabbit is not eating or drinking, the doctor may also recommend that fluids be administered subcutaneously and that syringe feeding be done several times a day.
Although lab studies done on inner ear infections reports a very poor cure rate, I have spoken to many individuals, and can personally attest, to having a high success rate in getting rabbits through this illness. The "secret" if there is one, is long term antibiotics, which is for a minimum of 30 days. However it is common for the rabbit to be on antibiotics for 6 months and even for the remaining years of his life and this must be in conjunction with a loving and supportive environment for him to feel safe in.

As with humans, the initial stroke can kill, but if it does not, then the rabbit will usually be left with one side of his face, and perhaps one entire side of his body, either unable to move or he will have great difficulty in moving the affected side. You can frequently notice that one side of his face will "droop" and one eye may not function properly.

A blow to the face, neck or head can result in an injury to the brain which can cause the rabbit to have a head tilt. Trauma could be caused from a panic reaction to a presumed intruder which caused the rabbit to run into the side of his cage or from a fall or various other means.

Encephalitozoon cuniculi
This is caused by a protozoan parasite which has migrated to the brain and caused paralysis. (See the HRJ Vol. III No. xx for a complete description of this parasite.)

Brain cancer could of course cause numerous problems, including head tilt.

Cervical muscle contraction

Round worms
There is no known cure for this. Ivermectin has been tried, but it does not penetrate the brain and therefore may only be a valid treatment before the worm has entered the brain and before any symptoms are observed. Diagnosis is difficult and expensive and can only be made upon death by sending the entire brain to a lab.

Fungal infections

This would include ingestion of lead or ingestion of a toxic plant such as the woolly pod milkweed.

How we can help our rabbit deal with his head tilt
Regardless of the cause, most cases of head tilt have similarities. The "down" eye (the one facing the floor) will usually not close and will require eye ointment to keep the eye moist, I usually use the ointment in both eyes n Lack of balance is what causes rabbits to "roll" and be unable to stand, so I try to pick them up as little as possible. When you must pick him up, hold him securely against your own body, to help him feel as stable as possible. Depending upon the size of your rabbit you can usually figure out how to confine him to a smaller space (perhaps a sweater box with the higher sides). Place one of the synthetic sheepskin rugs (that allows urine to pass through but will keep the bun dry) on the floor of the cage or box, and then place rolled towels or small blankets to help prop him up, so that he will be less likely to roll when he loses his balance.
It seems to me that most rabbits will keep eating, but only if you hand feed him and include lots of sympathy with every bite of food. He may not want his pellets, but he will usually eat a variety of fresh green veggies, carrots and fruits if you hold them for him. As long as he continues to eat veggies Iíll also switch from timothy to (usually not recommended) alfalfa hay to encourage him to eat lots of roughage.
However, if your rabbit decides to decline food you will have to be ready to syringe feed him. There are many recipes for syringe feeding and you can be fairly creative. The primary point is to get food down him so that his gut doesnít stop moving, which would add further complications to the process of getting him well. A sample recipe might be pellets mixed with 2 parts water, Gerbers mixed garden veggies, some banana, some powdered acidophilus, some apple sauce (some of 0whatever he usually likes that has a strong taste). Feed him as frequently as possible throughout the day, and as much as you can get down him at each feeding. When he clenches his teeth and wonít swallow, Iíll stop for awhile and try more later.
Regardless of the cause, sometimes a rabbit will be left with a slight head tilt for the rest of his life.

Vet to Vet
Diagnostic approach to torticollis in rabbits
- Eliminate facial trauma
- Eliminate otitis externa
- Vestibular dysfunction
* Neurologic exam
∑ Peripheral (+nystagmus + ataxia)
* Examine for ruptured tympanic membrane
1. Culture & sensitivity of exudate
2. Treat with appropriate antibiotics
* Radiograph tympanic bullae. Test for Pasteurella multocida antibodies
1. If otitis media, treat with appropriate antibiotics
2. If negative for otitis continue with diagnostics for central neurologic problem
∑ Central (+nystagmus + ataxia, + postural reaction deficits)
* Cerebellar (+tumors)
* Vestibular nuclei (-tumors)
* Encephalitis (additional neurologic deficits)
1. Serology for E.cuniculi
2. Emperic therapy, if progressive:
. CSF tap for cytology & culture
. Investigate neoplastic, parasitic, or toxic etiology.
If possible exposure to Baylissascaris eggs, histopathic examination for multifical areas of encephalomalacia will help confirm the diagnosis.

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