I watched Anastasia walk. Ears? Fine. Eyes? Normal. Teeth? Perfect.
Michelle Gerhard Jasny, V.M.D. has been practicing veterinary medicine on the Vineyard since 1982 and writing the Visiting Vet column for more than 25 years. She lives and works in West Tisbury. She can be reached at firstname.lastname@example.org.
As usual, I started my morning perusing the day’s schedule. Although we computerized decades ago, I have never let go of my good old-fashioned, spiral-bound, paper appointment book, where we scrawl in good old-fashioned number two pencil — owner’s name, pet’s name, species, reason for visit, phone number. The day looked fairly routine. Recheck cat with hyperthyroidism. Lyme booster. Annual physical. House call to cat at assisted living residence. Dog with red eye. Cat with head tilt. I paused. Who had the head tilt? A 13-year-old Russian Blue cross named Anastasia whom I had known since she was a little four-pound kitten.
Holding the head angled to one side is referred to by veterinarians as a “head tilt.” It can be a symptom of a wide range of problems, from the benign to the life-threatening. Head tilts in cats usually fall into three categories. The first group is cats experiencing discomfort around the head or neck from things like ear infections, bite wounds, abscesses, or dental disease. In these cases, the animals are just intermittently tilting their heads in response to pain or itchiness, such as that caused by the teensy ear mite, Otodectes cynotis.
Okay, some people say they can see these mites with the naked eye, but to my 59-year-old peepers, ear mites are microscopic. (Dogs rarely get ear mites but they do get frequent bacterial or and/or yeast ear infections, which may lead to skin infection that spreads down the neck or across the side of the face. They will often rub their faces on the floor and shake their heads vigorously. Cats are less melodramatic.) Your veterinarian can diagnose and treat ear mites, abscesses, skin and external ear infections easily.
Many cats will also tip their heads when eating a particularly hard or chewy item. This may indicate oral pain, so your veterinarian will want to take a good look in your cat’s mouth, but for some cats it is just a normal, idiosyncratic feeding behavior. The key point is that with all these conditions, these cats can and will hold their heads in a normal position at least some of the time, and careful examination reveals a demonstrable cause for their behavior.
If Anastasia’s head tilt is truly constant, then the problem is probably in her vestibular system, the body’s balance mechanism that helps an animal know which way is up. The middle and inner ear comprise the peripheral vestibular system which then connects via the eighth cranial nerve to the central vestibular system in the brain. It is not always easy to determine if the problem is peripheral or central. Symptoms of peripheral vestibular disease may include persistent head tilt (always to the same side), rhythmic horizontal or rotary flicking of the eyes called nystagmus, walking in circles, falling to one side, an uncoordinated gait called ataxia, and vomiting. It can be caused by trauma to or infection of the middle or inner ear, nasopharyngeal polyps, tumors, or drugs that are damaging to the inner ear, but in cats far and away the most common type of peripheral balance disorder is idiopathic feline vestibular syndrome.
The pathophysiology of feline vestibular syndrome is unknown, hence the term “idiopathic.” It comes on very quickly, often in the matter of a couple of hours. Most common in older cats, any age may be affected. It occurs more frequently in late summer and early fall, though no one knows why, but can happen any time of year. When an owner sees their kitty suddenly staggering around, walking in circles, sometimes unable to stand, it is not surprising that they assume the worse, but feline vestibular disease is actually no big deal.
For the first one to two days, cats may feel “seasick,” leading to loss of appetite, nausea, and vomiting, but this usually resolves quickly. Diagnosis is made based on the history, clinical signs, and ruling out other problems. You can do every test in the book, from blood work to X-rays to MRI, and they will all be normal. There is no specific treatment, although in severe cases your veterinarian may prescribe anti-nausea medications such as Dramamine ® or Antivert ® but no mediation of any kind has been found to alter the course of the disease. The most important thing is nursing care, keeping Anastasia in a safe, protected environment and providing easy access to food and water until the signs resolve. Most cats start improving within days and recover completely over several weeks.
This doesn’t mean that if your cat is staggering around, you can skip a visit to the vet. There are many serious problems with similar signs, and you need a professional to assess the situation. Central vestibular disease can be the result of head trauma, infections, brain tumors, even “stroke,” though that is rare in cats.
Signs of central balance disorders are very similar to those of peripheral disease but may include weakness on one side of the body and proprioceptive deficits. (Proprioception is the ability to sense the body’s position, motion, and equilibrium. In other words, to know where your feet are.) Animals with central disease may have altered mental status, seeming depressed or even stuporous. With peripheral disease, Anastasia might be disoriented but she would still be completely alert and responsive.
When our little Russian princess arrived, I realized the main reason for her visit was simply her annual physical and rabies vaccination. She waltzed out of her carrier, head completely straight. “Tell me about the head tilt,” I asked, looking her over.
Well, it seems her dad likes to hand feed Anastasia delicious little tidbits. Her owners noticed she would tilt her head to one side as she licked the proffered treat. I watched Anastasia walk. Ears? Fine. Eyes? Normal. Teeth? Perfect.
“I think she’s just a dainty eater,” I concluded, inwardly laughing at myself for having spent my morning worrying about those two words, “head tilt,” scrawled in my appointment book in good old-fashioned number two pencil.