Head tilt workshop

CASE 1

3Yr old cocker spaniel

Sudden onset head tilt

Neurological examination

Right sided head tilt

Spontaneous nystagmus (slow to right)

Right sided facial Paralysis

Right eye dry eye (Schirmer 5mm/min)

Anisocoria (R eye

thoughts?

-A right sided head tilt suggests right vestibular dysfunction which also explains spontaneous nystagmus slow phase to right

-Right sided facial paralysis suggests right facial nerve CN VII involved

-facial nerve lesion causes loss of parasympathetic innervation to lacrimal gland and so would explain right eye being dry

-Anisocoria showing right is smaller than left suggests possible horners syndrome where we get right miosis due to loss of sympathetic output

-we can conclude a peripheral lesion affecting CN VII, VIII so may be located in right inner/middle ear

ddx for case

Differentials

D N/A

A N/A

M - thiamine deficiency-> v rare in dogs so unlikely

N - middle ear tumour, nasopharyngeal polyps

I - otitis interna, idiopathic

T - temporal bone trauma, ototoxic drugs

V N/A

treatment for case 1

-Treatment if likely otitis media/interna or idiopathic vestibular disease is antibiotics, NSAIDS, steroids for idiopathic.

Both can clear on own.

Supportive treatment includes anti-nausea and eye lubrication to prevent ulcers

ct referral if want

Explain why otitis media/interna is high on DDx

-common cause of combined vestibular and facial paralysis

-diagnose with otoscopy where you see tympanic membrane thickening and yellow colour

-may see pain when opening mouth

-image with CT/MRI

Describe idiopathic vestibular disease

-common in older dogs

-self limiting (resolves on its own)

-sudden onset

-no ear disease

Describe nasopharyngeal polyp

-common in cats

-can extend to middle ear or nasopharynx

-may see mass in ear or throat potentially

main features of horners

miosis, third eyelid, drooping of face + sunken eye

whats difference between central and peripheral vestibular disease

• Central = see propioception deficit + mentation

• Peripheral = proprioceptive fine, Hornernʼs + facial nerve

what nn run out of the internal acoustic meatus

Facial nerve + vestibulocochlear + sympathetic fibres

CASE 2

8yr old golden retriever

Sudden onset facial asymmetry

O reports otherwise normal

Neurological examination shows head shape as photos

Otherwise NAD

-Images show facial asymmetry

-temporal muscle atrophy on left hand side which is supplied by trigeminal nerve

Trigeminal

• 3 branches

  • Opthpalmic, mandibular, maxillary

Mandibular = motor to mastication muscles

Abnormal left side

Sudden onset = red herring

Idiopathic - bilateral

ddx for case 2 and likely diagnosis

Differentials

D N/A

A N/A

M N/A

N - trigeminal neoplasia

I - trigeminal neuropathy (dropped jaw, inability to close mouth, drooling)

T N/A

V N/A

trigeminal neoplasia

what is seen in trigeminal neoplasia and trigeminal neuropathy

trigeminal neuropathy whuch has a sudden onset and is disfunction to the trigeminal nerve, usually present with open mouth and unable to close

-neoplasia of trigeminal neve however less common, we see progressive loss of muscle mass on one side

Case 3

3yr old aerdale terrier

Progressive dysphagia and behaviour chnage

§Rapid progression of dysphagia (apparent difficult prehension and swallowing with hypersalivation)

§Progressive behavioural change becoming cautious and shy

§Neurological examination not performed

thoughts

=Forebrain - behaviour issue

Vagus nerve - hyper salvation(ans) + dyphagia + efferent (efferent neurons carry motor commands away from the CNS to muscles and glands.)

Behaviour - distressed

Laryngeal paralysis - vagus

Glossopharyngeal - afferent (Afferent neurons carry sensory information to the central nervous system)-> affecting the motor for eating

differentials for case 3

D - degenerative leukoencephalomyelopathy (any disease that affects the white matter of the cns)

A N/A

M - hepatic encephalopathy (liver disease so blood flow bypasses the liver -> neurotoxins not removed (ammonia), build up in blood and go to brain

N N/A

I - meningoencephalitis, canine distemper, rabies, FB

T TBI

V - brain stem ischaemia

Outcome

Rabies

Isolate + call APHA

Case 4

Progressive lumbar pain

8yr old rescue cross bred from romania

§Progressive development of lumbar pain

§Neurological examination

§Proprioceptive assessment NAD

§Reluctance to sit or climb stairs

§Severe pain on palpation of the lumbosacral region

thoughts

Romania = imported, ask travel history

lumbosacral region

IVDD - no breed disposition

Neoplasia - expect

Discospondylitis (infection of disc causing pain) - common in Romanian

imports in LS region

• radiograph to diagnose

• MRI if non conclusive

• Brucella Discospondylitis common - imports

• Can run C&S on urine/blood or broad spectrum antibiotics for at least 6 weeks

Trauma/fracture - unlikely as presentation not serve enough

Ensure if aspirate then tell lab from Romania as do not want to expose people

to Brucellosis

out come for case 4= brucella.

how does this cause discospondylitis

bact spread and get infection of an intervertebral disc and adjacent vertebral endplates

ddx for case 4

D - degenerative lumbosacral stenosis (spinal canal narrows at the junction between the last lumbar and the sacrum), IVDD, arthritis

A N/A

M N/A

N - vertebral neoplasia

I - brucellosis-> discospondylitis (spinal abscess)

T - chronic pelvis injury / lumbosacral instability

V N/A