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
Have something to add? Comments (if open) will appear within 24 hours.
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.
Hi, I have a 10yo chihuahua/daschund. He displayed symptoms of a right ear infection one day and a head tilt later that day. The vet prescribed a 5 day abx and 10 day steroid w taper, and ointment to the affected ear. He seems to get better, was eating , drinking & wanting to play fetch. 2 nights ago, he got confused asking to come up to my bed-he was by the wall, thinking it was the bed ( my room is pitch black though). Neither of us slept, unprepared to go to the vet Friday am when they opened. I ended up going to the pet ER at 4am because he yelped out what I thought was pain. The doc prescribed gabapentin and a 10 day course of amoxicillin/claviculonic acid. She thought he had pain & a lingering inner ear infection , poss ruptured membrane. Head tolt still there. Last night, we slept on the couch & he woke up yelping & scared & had a grand mal seizure. I was scared as well, I lightly held him for the 20-30 seconds. I raced back to the vet, anticipating I’d have to put him to sleep, but he had relaxed and could stand by the time we got to the ER. The vet rec a CT (I can’t afford! It’s 3k) but I wonder if long term antibiotics would work???? Do I ask my regular vet for more after this 10 day course is completed? What if he has another seizure? I’m so distraught. He is still eating & drinking water. I use a harness to help him maintain balance when we go potty
Hi Valerie. I have several comments. Firstly, I can’t speak to your area, but we can get a CT on an animal done here for $1000 so I would look more widely at other facilities even if you have to travel. It is definitely the best test. If you can’t do this, it is sometimes possible to resolve inner ear infections with long-term antibiotics, plus ear flushes and local treatments combined. Others will require TECA surgery. It will involve much follow-up and eventually cost more than a CT, but won’t be a big lump sum. Bear in mind, though that although the diagnosis is likely, it is not confirmed.
Thank you. I will look around for CT availability. It seems like he is more dizzy and less eager to walk around these last couple days. It has just been a little over 24 hours since the second round of antibiotics were started. The increased dizziness is concerning to me, as well as scary and sad to watch. I feel like I am making him suffer, although he gobbled down the boiled chicken and scrambled egg with peas & carrots. No seizure in 24 hours now. Other than a brain tumor, a bad infection can cause this for sure? Maybe he wasn’t on antibiotics long enough the first time &’the infection got worse
I was hoping you had a reply on this. The same thing is going on with my 14 year old Boston.
Hi Cathy. Regarding Valerie‘s follow-up question, these dogs can’t generally be fixed by antibiotics alone, no matter how long the course is, although they are often very palliative.
Hello,
My 10yr old lab hound mix has been experiencing symptoms of vestibular disease for about 2 weeks. It started with weakness in his back legs and vomiting. It progressed to a head tilt and vertigo about 10 days ago. He was prescribed a antibiotic and improved from Monday to Wednesday to where he was 90% normal. He regressed since Thursday to today (Wednesday following week). He has been unable to really stand without assistance. He was prescribed Prednisone and started that 3 days ago but hasn’t shown any sign of improvement. He also lost his bark, and what appears to be most of his hearing. He is eating and drinking. His thyroid levels are normal (w/ .5 mg 2x/day of thyroid medicine) and blood tests showed nothing remarkable. Any suggestions?
Hi Brent. Sorry, nothing simple comes to mind. If you were in South Australia, I would recommend a CT scan, but there may be other diseases in your local area to consider first. Good luck.
My two year old was admitted to out If hour vets with suspected vestibular syndrome his eyes was flickering and he was going in circles
They put him on ivf but the canular come out so they suggested sedation the drug was met something
But he didn’t respond too well to that coughing up blood and struggling to breath , when this started to wear off he was rolling around quite a lot so it was then suggested to give him diazepam
They said he had responded well his eyes wasn’t flickering and he was more relaxed this was at 6pm at 9pm we was told his heart stopped and they didn’t hold much hope but we as keeping him alive , this is where I can’t get my head around , I read extensively about vestibular and although it wasn’t pleasant for the dog they rarely died as a result of it . The vet said after telling us constantly that it was vestibular she then suspected a brain tumour this is why he passed ?? I feel it was more drug related than anything else as he would of needed a mri to say he had a brain tumour ?
I he was a strong otherwise healthy two year old boy until this happened
Hi Sam. Vestibular signs can be caused by anything that damages that part of the brain, so in your poor doggy’s case, it was almost certainly something other than the common idiopathic vestibular syndrome.
My two and a half year old cockapoo has been tilting her head for at least two weeks and shows no other symptoms of vestibular disease. She shows no signs of discomfort,, is eating well and has normal energy level. The vet suspects inner ear infection and prescribed 8 days of cefaseptin 300mg. Looking back, I wonder if she might have had an inner or middle ear infection for a long time. She used to scratch at her ear somewhat frequently but there was never any obvious sign of ear infection such as drainage or odour, or signs of discomfort . She is on day 5 of an 8 day course of antibiotics . Should I take her for an MRI if the antibiotic does not result in any improvement?
Hi Becky. It’s a good idea to investigate further as what is happening has no obvious cause.
Thank you so much for taking the time to provide information and advice to worried pet owners. I will take her for the MRI.
Hi Andrew, lathe full course of antibiotics did not have any effect, I had my dog evaluated by a veterinarian who specializes in neurological issues. She suspected an inner ear infection or meningitis but also said that it might be idiopathic and recommended an MRI and a spinal tap. Neither test revealed any abnormalities. Her conclusion was that the head tilt with no other symptoms is idiopathic and not a concern. A big hit to my bank account but now I have peace of mind.
My dog had baldder surgery then right into head tilt but was eating drinking and peeing as stine got removed. But then before he could start walking around block he was tilting head and not being able to walk which shit down all legs and no walking eveni g for bathroom. He looked like he was have stokes as days went on. So we made choice to put him to sleep. Breaking my heart he was my emotional support dog for 5yrs way too young. My belief is he should of had blood thinners after surger… ALFIE was my everything…just got ashes back today… sad moments
Hi Mike. That’s a terrible story, but don’t be too hard on your vets. I have never heard of such a thing happening and there’s no way it could’ve been predicted in advance. You did everything you could.
I have a 15 year old min- pin. She was diagnosed with TCC cancer on Nov 9, 2021. Operating isn’t a solution. Wednesday (5/17) Razz passed out or had a stroke. We are not sure. Afterwards she was fine but was tried and I watched her closely plus called her vet. Three days later (5/20) Razz is tilting her head, will stop walking and will just stand with her head down plus she seems to want to stretch but can’t.
Razz will be fine for about an hour or two then she will start showing sings again. With out a MRI the vet is not sure. She is a high risk to but under for a MRI. I don’t want to lose her this way. I was told it’s probably vestibular disease. If she gets worst it’s central if not it’s peripheral. I would like your thoughts on what you think especially since she is 100 percent ok for several hours in a day but not 24/7. Razz is on steroids, Benadryl, anti acne meds, antibiotic and a medication for nausea. She has been on all of these medications for months/years. She was on Piroxicam twice and it started to attack her liver for the second time. That’s why the steroids are being taken now. Any thoughts are appreciated.
Hi Lora. Sorry, I can’t offer any more thoughts.
Hi there,
I have a 2 year old french bulldog who 5 months ago had a strange episode, hid under the table, appeared frightened, head tilt and enlarged eyes. Told vet back then, he didnt seem worried. It happened again this morning, 5months on, same thing. Took him to vets.Bloods were ok, slight increase in red, vet said could be dehyration. Vet thinks dog could have epilepsy and prescribed medication.
Would you agree it could be epilepsy? I would like to note, dog has had some reflux issues, changed his diet which is now working and no issues. otherwise hes healthy.
Hi Julie. I think your vet is probably referring to something like a partial seizure, which is indeed a good thought. Of course, it’s so hard to know with such a vague behaviour like this. There shouldn’t be much harm in following your vets’ recommendation and seeing if the medication brings improvement. However, as you’ve been only two episodes, it might be hard to know if the medication is helping.
Hi, I have a puppy that showed a head tilt from 3wks. He’s a chihuahua and saw a vet @4wks when I noticed him trying to scratch at his ear but his ears weren’t open for the vet to look. He continued to grow and shows no other worrying symptoms other than head tilt. He’s checked again at 10 & 14 wks but no sign of ear infection. He’s now 5months old and the head tilt is slight. I don’t have the money for MRI. I can’t find any information on dogs born with head tilt so I don’t know what his future holds. He seems like a normal puppy. Do you have any insights. Thank you
Hi Philippa. Given the signs of scratching at the ear that you noticed I would be concerned that there was and still is an early middle or inner ear infection as I have seen this before. It may be that it is contained and will pose no further problems other than the residual head tilt, but as you know, without imaging, it is impossible to be certain.
You didn’t mention meningoencephalitis was a possible reason specifically. Is there a treatment?
Hi Cheryl. If you have another look you’ll see that meningoencephalitis is actually mentioned twice in the article. Treatment however is a large subject and of such urgency that you should talk to your vet ASAP.