Head Tilt

Rotation of the head (head tilt) is an alarming symptom of several rabbit diseases. It is also called torticollis or wry neck.

Head tilt varies from a subtle tilt with one ear carried a little lower than the other to severe rotation where the head appears to be upside down.

There are many different causes, depending on which part of the rabbit’s complex balance and control system is affected.

• Ear disease – the visible part of the ear is the outer ear. This connects to the deeper parts of the ear, the middle and inner ear. Infection in the outer ear, nose, throat and other parts of the body can spread to the middle and inner ear. Ear mite infestation can also lead to deeper bacterial infection.
• Structures within the inner ear give the brain information about balance. They transmit information about the position of the head and the rest of the body. When infection and inflammation is present the brain no longer receives these messages and head position, coordination and balance are lost. This is called peripheral vestibular disease. Trauma to the ear or tumours in the ear will have the same result.
• Brain disease – central vestibular disease involves damage to the brain that process the information about balance. The symptoms are the same as the peripheral form, but they are often more severe. This can be caused by head trauma, tumours or infection. Infection can be caused by bacteria, viruses or parasites. Encephalitozoon cuniculi (E. cuniculi) is an important protozoan parasite that can cause inflammation in the brain and kidney of the rabbit. Cerebrovascular accidents (stroke) can cause brain injury.
• Toxicity – Lead and zinc are present in some older paints. If the rabbit nibbles on painted surface, toxicity can lead to head tilt, loss of balance and seizures. Some over the counter dog and cat parasite treatments will cause these symptoms in rabbits. Some plants are toxic to the nervous system, for example, hemlock and milkweed.
• Liver disease – advanced liver disease can cause weakness, confusion, head tilt and seizures.
• Dietary imbalance – vitamin and mineral imbalances can cause neurological symptoms.
• Neck trauma or pain – can result in head tilt as the muscles on one side of the neck contract.

Head tilt can prevent eating, drinking and grooming leading to dehydration, weakness and infection.

The disease causing the head tilt may be life-threatening.

Head tilt can occur gradually or suddenly. Incoordination, weakness, lethargy or a loss of appetite may precede the head tilt. The rabbit may appear disoriented or confused.

Head and ear shaking are likely.

One side of the face may droop and the rabbit may drool. One eye may appear sunken, the third eyelid (in the corner of the eye) may cover the eye. The rabbit may be unable to blink.

The eyes may flicker repeatedly from side to side or up and down. This is called nystagmus and suggests vestibular disease. The rabbit may have different sized pupils.

They may lean against the hutch wall and fall over if unsupported. Muscle weakness may be one sided and they may walk in circles. Some severely affected rabbits roll over constantly. They often cannot move or stand normally.

Rabbits with a head tilt should be taken to the vet quickly. The vet will check the rabbit, using an otoscope to examine the ear and perform neurological tests.

If ear infection is identified then your rabbit may need investigation to ascertain how far the infection has spread. Sedation for x-ray and aspiration to sample infected material may be necessary. Middle and inner ear infections must be treated with long courses of antibiotics. Surgery may be undertaken to flush out the ear canals. An ear mite infestation will be treated. Anti-inflammatory drugs may also be used to manage pain and inflammation.

If brain disease is suspected then a CT or MRI scan is ideal. If this is not possible then presumptive treatment with antibiotics and anti-inflammatories may be used. It is possible to test for E. cuniculi but a positive result does not mean it is the cause of the head tilt. Therefore, your vet may choose to treat for this parasite.

If your rabbit has been exposed to toxins, removal from the toxin and specific treatment may be needed. Blood tests may be necessary to investigate dietary imbalance and liver disease. Feeding a balanced diet will improve neurological signs if there are dietary imbalances. Neck pain can be treated with pain relief and physiotherapy.

The success of treatment depends on the cause of the head tilt and the severity of the disease. Half the rabbits who present with a head tilt will improve with appropriate treatment. Some are left with a head tilt that does not affect their long term health. Unfortunately, some rabbits have severe disease and do not recover despite appropriate care. These rabbits may be unable to eat, drink or move around normally. If they are unresponsive to treatment, it may be kinder to consider euthanasia.

Head tilt can be an alarming symptom and prompt intervention is essential. However, remember that many rabbits will recover and have an excellent quality of life.

Nursing is imperative for the recovery of these patients.

• Food and water – the affected rabbit may struggle to locate, pick up, chew or swallow food. It may be necessary to syringe feed your rabbit. Your vet can advise you on a recuperative food and how to syringe feed slowly and gently. Tempting food such as carrot sticks should be presented in small pieces. Affected rabbits may be unable to clean and eat caecotrophs so remove them gently and mix them with their food. Similarly, your rabbit may need fluids administered at the veterinary practice or by syringe at home.
• Their enclosure – restricting activity can prevent further injury and exhaustion. Their enclosure should be large enough to lie in comfort and move around a little. It should be flat with no obstacles and soft bedding on the floor. These patients cannot negotiate steps or ramps and they may need to be propped up to stay upright. Your rabbit may need to be isolated but including materials with companion and owner scent on them may keep them calm. Bedding should be dry and fresh and changed regularly.
• Movement – if your rabbit is unable to stand, he or she should be turned regularly. Bed sores can be prevented by extra, soft padding over hocks and elbows. Encourage some movement in a safe place to maintain muscle tone.
• Handling – handle your rabbit gently and reduce any stress in their surroundings. Keep them away from predators, loud noises or bright lights. Groom them gently to care for their coat.

Recovery can be slow.

• Treat any infections as soon as possible, particularly respiratory and ear infections.
• Observe your rabbit’s behaviour carefully to pick up subtle changes that may alert you to disease.
• Seek help promptly if your rabbit develops a head tilt.
• Treat new rabbits for E. cuniculi before introducing them to your rabbit.
• Prevent overcrowded, stressful living conditions and keep their enclosure clean.