Received: 30 June 2020 Revised: 4 November 2020 Accepted: 9 November 2020

DOI: 10.1002/vetr.61

ORIGINAL RESEARCH

Clinical reasoning in canine vestibular syndrome: Which

presenting factors are important?

Eleanor Harrison1 Nick J. Grapes1 Holger A. Volk2 Steven De Decker1

1
Clinical Science and Services, Royal Abstract
Veterinary College, University of London,
Hatfield, UK
Background: Although the use of clinical reasoning has been evaluated for
2
several neurological presentations, this approach has not yet been investi-
Department of Small Animal Medicine and
Surgery, University of Veterinary Medicine,
gated for dogs with vestibular syndrome.
Hannover, Germany Methods: Two hundred and thirty-nine dogs presenting with vestibular syn-
drome were included in this retrospective study. Univariate analysis of vari-
Correspondence ables (clinical history, signalment, clinical presentation and neurological
Steven De Decker, Clinical Science and Ser-
vices, Royal Veterinary College, University of
examination findings) was performed. Variables with p < 0.3 were selected
London, Hatfield, United Kingdom. for logistic regression.
Email: sdedecker@[Link] Results: Ninety-five percent of dogs were represented by eight conditions:
idiopathic vestibular disease (n = 78 dogs), otitis media interna (n = 54),
[The copyright line for this article was meningoencephalitis of unknown origin (n = 35), brain neoplasia (n = 26),
changed on 27 April 2021 after first online
publication]. ischaemic infarct (n = 25), intracranial empyema (n = 4), metronidazole toxic-
ity (n = 3) and neoplasia affecting the middle ear (n = 3). Idiopathic vestibular
disease was associated with higher age, higher bodyweight, improving clini-
cal signs, pathological nystagmus, facial nerve paresis, absence of Horner’s
syndrome and a peripheral localisation. Otitis media interna was associated
with younger age, male gender, Horner’s syndrome, a peripheral localisation
and a history of otitis externa. Ischaemic infarct was associated with older age,
peracute onset of signs, absence of strabismus and a central localisation.
Conclusions: Discrete clinical features can be used to identify the most likely
diagnosis in dogs with vestibular syndrome.

INTRODUCTION cerebellum.1,4 It is clear that obtaining a diagnosis

of disorders affecting the central vestibular system
Canine vestibular syndrome is a commonly encoun- requires more advanced and expensive diagnos-
tered presentation in clinical practice. The term tics compared to disorders affecting the peripheral
encompasses over 20 different diagnoses, which vestibular components.6 Although several neurolog-
are associated with variable diagnostic approaches, ical examination findings, such as decreased menta-
treatment recommendations and prognoses.1,2 Head tion, proprioceptive deficits and cranial nerve deficits
tilt, ataxia, nystagmus and positional strabismus can help confirm the presence of central nervous
are common clinical signs in dogs with vestibular system involvement,3,7,8 the absence of these findings
syndrome.1–5 Although observation of these clinical does not exclude the presence of central disease.4,6,9
signs facilitates recognition of vestibular system dys- Recent studies have demonstrated the limitations
function, they rarely assist in determining the under- of using neurological examination findings to reli-
lying cause of disease. ably differentiate between central and peripheral
The vestibular system is anatomically divided into vestibular syndrome in dogs.6,9 It therefore remains
peripheral and central components.1,4 The periph- challenging for veterinary practitioners to correctly
eral vestibular system includes the receptors in the identify those cases that will benefit from referral for
membranous labyrinth in the inner ear and the advanced diagnostic modalities, such as magnetic
vestibulocochlear nerve, while the central vestibu- resonance imaging (MRI), computed tomography
lar system includes structures in the brainstem and (CT), and cerebrospinal fluid (CSF) analysis.6 It is
furthermore likely that not all owners will accept or
Abbreviations: CT, computed tomography; MRI, magnetic resonance will be able to afford referral to specialist centres.
imaging; MUO, meningoencephalitis of unknown origin

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction
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© 2021 The Authors. Veterinary Record published by John Wiley & Sons Ltd on behalf of British Veterinary Association

Vet Rec. 2021;e61. [Link]/journal/vetr 1 of 10

[Link]
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2 of 10 Veterinary Record

Due to the difficulties in determining aetiology review or if no presumptive or definitive diagnosis was
without further diagnostics, robust clinical reason- reached.
ing is paramount in order to recognise the most
likely differential diagnoses, suitably select cases
for advanced investigations and potential referral.
Disease categories
Clinical reasoning is the critical thinking process
All medical records and diagnostic studies were
in which cues of clinical information are used to
reviewed by a board-certified neurologist (Steven De
influence clinical decision-making.10 This decision-
Decker), and dogs were allocated to one of the follow-
making process directs the clinician towards taking
ing eight disease categories: 1) idiopathic vestibular
the most suitable action in a specific context and has
disease, 2) otitis media interna, 3) meningoencephali-
been considered ’critical and central to veterinary
tis of unknown origin (MUO), 4) brain neoplasia, 5)
practice’.11,12 Previous studies have demonstrated
ischaemic infarct, 6) intracranial empyema, 7) metron-
the usefulness of clinical reasoning in a variety of
idazole toxicity and 8) neoplasia affecting the middle
common neurological presentations, including spinal
and/or inner ear structures.
disease and epilepsy in dogs and cats.13–16 Although
For the purpose of this study, idiopathic vestibu-
a recent study has evaluated associations between
lar disease was considered if no abnormalities were
the clinical presentation, MRI findings and outcome
observed on MRI or any other diagnostic tests.1–4
in dogs with peripheral vestibular syndrome,17 it is
Dogs had to have MRI performed and total T4/TSH
currently unclear if clinical reasoning can reliably
evaluated with normal results to be considered for
be used to identify the most likely differential diag-
this diagnostic category. Otitis media interna was
noses in dogs with peripheral or central vestibular
considered when MRI or CT demonstrated a fluid
syndrome.
accumulation in the middle ear.3 In all dogs this diag-
The aim of this study was therefore to evaluate if
nosis was further supported by cytological evaluation,
discrete clinical characteristics, such as signalment,
otoscopic examination, myringotomy or surgical
clinical history, clinical signs and neurological exam-
findings.1,5,18,19 A diagnosis of neoplasia affecting
ination findings, can be used to generate a prioritised
the middle and inner ear was considered when MRI
list of differential diagnoses in dogs with vestibular
or CT demonstrated an abnormal mass with soft
syndrome. We hypothesised that statistical modelling
tissue intensity or density affecting the middle and
could be used to identify significant associations
inner ear structures, which was further confirmed by
between easy to identify clinical variables and the
histopathology.3 A diagnosis of ischaemic infarct was
most common causes of vestibular syndrome in dogs.
considered when MRI of the brain revealed a sharply
It is hoped that such information will provide veteri-
demarcated homogenously T2W hyperintense lesion
nary practitioners with clinically useful information
in relation to a known arterial territory, which was not
when assessing dogs with vestibular syndrome in first
associated with mass effect and did not enhance after
opinion practice.
IV contrast administration.20 Intracranial empyema
was characterised by extension of otitis media interna
MATERIALS AND METHODS into the brainstem. This diagnosis was based on a
combination of compatible MRI and CSF findings.21
Included animals Metronidazole neurotoxicity was considered in dogs
receiving high doses (>65 mg/kg/day) of metronida-
This study was approved by the Social Sciences Eth- zole, with compatible MRI findings, and in which
ical Review Board of the Royal Veterinary College, clinical signs improved after obtaining a diagnosis
University of London (RVC, URN SR2017-1342). The and discontinuation of metronidazole.22,23 Diagnostic
digital medical database of the Small Animal Refer- criteria for MUO24,25 and brain neoplasia26 were based
ral Hospital of the Royal Veterinary College was ret- on previously published literature.
rospectively searched for dogs with vestibular syn-
drome between 25 June 2010 and 12 July 2018. Search Evaluated clinical variables
terms included ‘vestibular syndrome’, ‘vestibular dis-
ease’, ‘head tilt’, ‘nystagmus’ and ‘strabismus’. To be For all included cases, the following information was
included in this study, dogs had to have received a retrieved from the medical records: signalment, body-
full neurological examination performed by a board- weight, clinical history of otitis externa, disease onset
certified neurologist or neurology resident under the and progression, mental status, gait and postural
direct supervision of a board-certified neurologist, full abnormalities, proprioceptive deficits, unilateral or
blood work, including haematology and a biochem- bilateral vestibular signs, presence and type of nys-
istry profile (including cholesterol and triglyceride tagmus, presence of a head tilt, positional strabismus,
concentration), and additional appropriate diagnos- Horner’s syndrome, facial nerve paresis, other cranial
tic investigations performed to obtain a reliable pre- nerve abnormalities and suspected neuro-anatomical
sumptive or definitive diagnosis. Dogs were excluded localisation. Onset (days to presentation) and progres-
if the medical records were incomplete, if none or sion were classified as categorical variables. Onset was
insufficient further diagnostic examinations were per- defined as peracute (<1day), acute (1–7days), suba-
formed, if the diagnostic studies were unavailable for cute (7–14 days) or chronic (>2 weeks). Progression
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Veterinary Record 3 of 10

was classified as static, progressive, improving or neuro-anatomical localisation (central or peripheral)

episodic, based upon the animal’s condition at the were included as binary categorical variables. Type
time of admission compared to the history from the of nystagmus was categorised as horizontal, vertical
referring veterinary surgeon and owner. An improved or rotary. Onset of clinical signs was categorised as
clinical status was assumed when the dog’s clinical peracute (<1day), acute (1–7 days), subacute (7–14
signs had improved spontaneously without any medi- days) or chronic (>2 weeks). Progression of signs
cal intervention from the referring or admitting veteri- was categorised as improving, static or progressive.
nary surgeon. Unilateral vestibular signs were defined Variables with p < 0.30 were retained and a logistic
as one or a combination of the following: vestibular regression, using the forced entry method, performed
ataxia, pathological nystagmus, unilateral positional for each of the five most prevalent diseases. The vari-
strabismus and head tilt. Vestibular ataxia was char- ables retained for multivariable logistic regression
acterised by leaning, falling, rolling or tight circling therefore varied between diagnoses. The small sample
to one side. Bilateral vestibular signs were defined as size of the majority of breeds limited the performance
one or a combination of the following: absence of an of logistic regression for this variable. Variables were
oculovestibular response and absence of a head tilt considered significant with a p < 0.05. A false dis-
in combination with other signs of bilateral vestibu- covery rate for multiple comparisons was performed
lar syndrome, such as a crouched and wide-based on the resultant p values.27,28 Results are presented
posture and pendular head movements.1,4 Suspected with odds ratios (OR) and 95% confidence intervals
neuro-anatomical localisation was categorised into for each condition compared to the rest of the popu-
central or presumptive peripheral vestibular system. lation. Non-normally distributed continuous data are
Dogs that displayed vestibular ataxia, strabismus or presented as median (range) while normal distributed
nystagmus and additionally one of the following: data are presented as mean (SD).
decreased mentation, cranial nerve deficits other than
facial or vestibulocochlear nerve dysfunction, pro-
prioceptive deficits, hypermetria, intention tremor or RESULTS
tetraparesis were considered to have central vestibular
syndrome.6,8 Dogs without any of these additional Three hundred and twenty-six dogs presented during
abnormalities were considered to have presumptive the study period for further evaluation of vestibular
peripheral vestibular syndrome. syndrome. Seventy-six dogs were excluded because
insufficient diagnostic procedures were performed,
and a further 11 dogs were excluded because no
Investigations reliable presumptive or definitive diagnosis could
be reached. Two hundred and thirty-nine dogs were
CT was performed with a 16-slice helical CT scan-
therefore included in this study. This group included
ner (PQ 500, Universal Systems, Solon; GE Health- 105 females (73 neutered) and 134 males (84 neutered)
care), under sedation or general anaesthesia. MRI
aged between 3 months and 14 years 10 months and
was performed under general anaesthesia with a
weighing between 1.6 kg and 63.9 kg. The Cavalier King
high-field unit (1.5T, Intera; Philips Medical Systems, Charles spaniel was the most common breed (n = 26
Amsterdam, Netherlands). Imaging studies included
dogs), followed by the French bulldog (n = 20), Boxer
a minimum of T2- and T1-weighted sagittal and
(n = 12), Staffordshire bull terrier, English springer
transverse images and transverse fluid attenuation spaniel (n = 11 for both), English cocker spaniel,
inversion recovery and gradient echo images. T1-
Shih-tzu, Golden retriever (n = 10 for each), Labrador
weighted images were acquired before and after IV retriever, Pug (n = 8 for both), Border collie, Chihuahua
administration of gadolinium-based contrast medium (n = 6 for both), West Highland White Terrier, Bichon
(0.1 mmol/kg gadoterate meglumine, Dotarem; Guer-
Frise (n = 5 for both) and Toy Poodle (n = 4). Twenty-
bet, Milton Keynes, UK). CSF was collected via a cister- six breeds were represented by three or fewer dogs,
nal puncture under general anaesthesia. A total nucle- and 22 dogs were cross breeds. In total, a presumptive
ated cell count (TNCC) below five cells/µL and a total
or confirmed diagnosis was made for fifteen disor-
protein concentration below 0.27 g/L were considered ders in the study population. Idiopathic vestibular
normal. disease was the most common diagnosis (n = 78 dogs
or 34.2% of included dogs), followed by otitis media
Statistical analysis interna (n = 54; 23.7%), MUO (n = 35; 15.4%), brain
neoplasia (n = 26; 11.4%), ischaemic infarct (n = 25;
Statistical analysis was performed using statistical 11%), intracranial empyema (n = 4; 1.8%), metronida-
software (SPSS V.[Link]; IBM). Univariate analy- zole toxicity (n = 3; 1.3%) and neoplasia affecting the
sis of the clinical variables was performed. Age and middle ear (n = 3; 1.3%). The remaining 11 dogs were
bodyweight were included as continuous variables. diagnosed with congenital cerebellar malformation,
Sex, presence of a head tilt, nystagmus, positional corticosteroid responsive tremor syndrome, hypothy-
strabismus, abnormal mentation, ataxia, postural roidism, primary secretory otitis media (n = 2 for each
reaction deficits, Horner’s syndrome, facial nerve disease), congenital vestibular syndrome, fucosidosis
paresis, other cranial nerve deficits, cervical hyperaes- and external trauma (n = 1 for each disease). In all
thesia, clinical history of otitis externa and presumed dogs diagnosed with idiopathic vestibular syndrome,
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4 of 10 Veterinary Record

total Thyroxine (T4) and Thyroid stimulating hormone (p = 0.003). Presence of Horner’s syndrome was
(TSH) was evaluated, and in 47 of 78 dogs with this associated with a diagnosis of otitis media interna
diagnosis, a CSF sample was evaluated. No abnormal- (p < 0.001), while absence of Horner’s syndrome was
ities were detected on these examinations. In 11 of 54 associated with a diagnosis of idiopathic vestibu-
dogs with otitis media interna, total T4/TSH was eval- lar syndrome (p = 0.005). Presence of cranial nerve
uated, and in 6 dogs with this diagnosis, a CSF sample deficits, other than facial nerve paresis and Horner’s
was evaluated. No abnormalities were detected on syndrome, was associated with a diagnosis of brain
these examinations. In 33 of the 35 dogs with MUO, neoplasia (p = 0.018) (Table 2).
a CSF sample was evaluated, and 21 of these samples
were submitted for PCR evaluation for infectious
diseases (Toxoplasmosis, Neosporosis and Canine Neuro-anatomical localisation
Distemper). Thirty of the CSF samples demonstrated
an abnormally elevated TNCC and increased protein, A presumptive peripheral neuro-anatomical locali-
while all of the PCR samples returned negative. In one sation was associated with diagnoses of idiopathic
dog with MUO, total T4/TSH was evaluated, which vestibular syndrome (p < 0.001) and otitis media
returned within normal limits. In eight of the 26 dogs interna (p = 0.009). A central neuro-anatomical local-
with brain neoplasia, total T4/TSH was evaluated, isation was associated with diagnoses of ischaemic
and in six dogs with this diagnosis, a CSF sample was infarct (p = 0.012) and brain neoplasia (p = 0.028)
evaluated. No abnormalities were detected on these (Table 2).
examinations. In all dogs diagnosed with ischaemic
infarct, total T4/TSH was evaluated, and in 8 of 25
dogs with this diagnosis, a CSF sample was evaluated. Clinical history of otitis externa
No abnormalities were detected on any of these exam-
inations. The clinical presentation and neurological A clinical history of otitis externa was associated with
examination findings of these dogs are summarised in a diagnosis of otitis media interna (p < 0.001). The
Table 1. absence of a clinical history of otitis externa was asso-
ciated with diagnoses of idiopathic vestibular syn-
drome (p = 0.007) or MUO (p = 0.037) (Table 2).
Signalment

Higher age was significantly associated with diagnoses DISCUSSION

of idiopathic vestibular disease (p < 0.001), ischaemic
infarct (p = 0.005) and brain neoplasia (p = 0.02). This study evaluated if distinct clinical characteristics
Younger age was significantly associated with diag- can be used to identify the most likely underlying
noses of otitis media interna (p = 0.015) and MUO diagnoses in dogs with vestibular syndrome. Our
(p < 0.001) (Table 2). Higher bodyweight was associ- results indicate that in our hospital, more than 95%
ated with a diagnosis of idiopathic vestibular disease of dogs with vestibular syndrome are represented by
(p < 0.001), and male gender was associated with a eight conditions and that four of the five most com-
diagnosis of otitis media interna (p = 0.018) (Table 2). mon causes of this clinical presentation (idiopathic
vestibular disease, otitis media interna, ischaemic
Onset and progression of clinical signs infarct and brain neoplasia) are statistically associ-
ated with multiple clinical variables derived from the
A peracute onset of clinical signs was associated with clinical history, signalment, clinical presentation and
a diagnosis of ischaemic infarct (p = 0.025). Improving neurological examination. Although it is clear that
clinical signs was associated with a diagnosis of idio- clinical reasoning cannot replace specific diagnostic
pathic vestibular disease (p = 0.025) (Table 2). tests, applying this methodology can assist veterinary
practitioners in creating a list of prioritised differ-
Head tilt, nystagmus and strabismus ential diagnoses in dogs with vestibular syndrome.
This could potentially further facilitate selection of
Presence of a head tilt was significantly associated with diagnostic tests, formulation of treatment recom-
a diagnosis of brain neoplasia (p = 0.034), the presence mendations, discussion of associated prognoses and
of pathological nystagmus was associated with a diag- selection of cases for referral and advanced diag-
nosis of idiopathic vestibular disease (p = 0.04) and the nostic procedures. Veterinary practitioners can feel
lack of strabismus was associated with a diagnosis of unconfident with neurological patients.29–32 This phe-
ischaemic infarct (p = 0.047) (Table 2). nomenon of ’neurophobia’29–32 is associated with a
reluctance of clinical practitioners to assess neurology
patients and perform a neurological examination.29,31
Facial nerve dysfunction, Horner’s It is therefore important to emphasise that the results
syndrome and other cranial nerve deficits of this study do not advise against the importance of
performing a neurological examination. Several of the
Presence of facial nerve paresis was associated identified variables, such as presence of facial nerve
with a diagnosis of idiopathic vestibular syndrome paresis, Horner’s syndrome, nystagmus and a central
 TA B L E 1 Signalment, clinical presentation and neurological examination findings of 228 dogs with vestibular syndrome

Other Central
Median History Facial cranial neuro-
Number age in Median of otitis Decreased Postural nerve Horner’s nerve anatomical
Veterinary Record

of dogs months weight externa mentation Ataxia Head deficits Nystagmus Strabismus paresis syndrome deficits localisation
(%) Gender (range) (range) Onset Progression(%) (%) (%) tilt (%) (%) (%) (%) (%) (%) (%) (%)

Idiopathic 78 M: 42 91 21.95 P: 7 Ep: 3 15 17 54 68 12 43 25 52 4 0 8

vestibular (34.2) F: 36 (21−165) (3.6−63.9) A: 58 Imp: 26 (19.2) (21.8) (69) (87.2) (15.4) (55.1) (32.1) (66.7) (5.1) (10.3)
disease S: 8 Prog: 17
C: 5 St: 32
Otitis 54 M: 38 72 12.4 P:2 Ep: 7 36 4 25 48 7 27 10 29 16 0 1
media/interna (23.7) F: 16 (7−128) (5.5−54.7) A: 29 Imp: 7 (66.7) (7.4) (46.3) (88.9) (13) (50) (18.5) (53.7) (29.6) (1.9)
S: 7 Prog: 17
C: 16 St: 22
Meningo- 35 M: 15 49.5 7 P: 2 Ep: 1 2 17 32 26 20 16 14 18 3 4 28
encephalitis of (15.4) F: 20 (6−125) (1.6−38) A: 29 Imp: 0 (5.7) (48.6) (91.4) (74.3) (57.1) (45.7) (40) (51.4) (8.6) (11.4) (80)
unknown S: 3 Prog: 32
origin C: 1 St: 2
Brain 26 M: 15 114 20.2 P: 0 Ep: 5 7 7 22 24 19 15 13 14 6 8 21
neoplasia (11.4) F: 11 (36−173) (7.2−38) A: 13 Imp: 0 (26.9) (26.9) (84.6) (92.3) (73.1) (57.7) (50) (53.8) (23.1) (30.8) (80.8)
S: 3 Prog: 16
C: 10 St: 5
Ischaemic 25 (11) M: 11 123 19.1 P: 9 EP: 2 2 5 19 17 16 15 5 10 3 2 18
infarct F: 14 (14−178) (2.2−36.7) A: 12 Imp: 7 (8) (20) (76) (68) (64) (60) (20) (40) (12) (8) (72)
S: 4 Prog: 8
C: 0 St: 8
Intracranial 4 (1.7) M: 3 71 11.55 A: 1 Prog: 4 2 1 3 3 3 1 2 2 0 0 4
empyema F: 1 (60-150) (8.7–16.7) S: 2 (50) (25) (75) (75) (75) (25) (50) (50) (100)
C: 1
Metronidazole 3 (1.3) M: 2 72 34.3 A: 3 Prog: 2 0 1 2 1 0 2 1 1 0 0 3
toxicity F: 1 (29–109) (9.5–60) St: 1 (33) (66) (33) (66) (33) (33) (100)
Middle ear 3 (1.3) M: 1 76 12.7 A: 1 Prog: 2 3 0 0 3 0 0 1 2 2 0 0
neoplasia F: 2 (65–115) (9.5–14.8) S: 1 St: 1 (100) (100) (33) (66) (66)
C: 1
Abbreviations: A, acute; C, chronic; Ep, episodic; F, female; Imp, improving; M, male; P, peracute; Prog, progressive; S, subacute; St, static.
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 TA B L E 2 Logistic regression analysis of signalment, clinical presentation and neurological examination characteristics of canine vestibular disorders with more than five cases
6 of 10

History of Neuro-
otitis Facial nerve Horner’s Other cranial anatomical
Gender Age Bodyweight Onset Progression externa Head tilt Nystagmus Strabismus paresis syndrome nerve deficits localisation

Idiopathic Older p < 0.001 Improving No Present Present Absent Peripheral

vestibular
disease
p < 0.001 OR = 1.09 p = 0.025 p = 0.007 p = 0.04 p = 0.003 p = 0.005 p < 0.001
OR = 1.03 CI: OR = 14.38 OR = 4.71 OR = 5.09 OR = 5.38 OR = 9.26 OR = 10.02
1.04–1.13
CI:1.01–1.04 CI:1.56– CI:1.72– CI:1.09–23.8 CI:1.99–14.5 CI:2.33–36.8 CI:2.98–33.7
132.21 12.91
Otitis media/ Male Younger Yes Present Peripheral
interna
p = 0.018 p = 0.015 p < 0.001 p < 0.001 p = 0.009
OR = 3.68 OR = 0.98 OR = 6.04 OR = 17.12 OR = 11.357
CI: 1.35– CI: CI: 2.31– CI: CI: 2.2–58.52
10.03 0.97–0.99 15.77 4.11–71.4
Meningo- Younger No
encephalitis
of unknown
origin
p < 0.001 p = 0.037
OR = 0.96 OR = 9.27
CI: CI:1.18–
0.93–0.98 72.73
Brain Older Present Present Central
neoplasia
p = 0.02 p = 0.034 p = 0.018 p = 0.028
OR = 1.02 OR = 21.04 OR = 14.96 OR = 5.83
CI: 1.0–1.04 CI: 1.36– CI:1.85– CI:1.29–26.5
325.17 120.89
Ischaemic Older Peracute Absent Central
infarct
p = 0.005 p = 0.025 p = 0.047 p = 0.012
OR = 1.03 OR = 148.9 OR = 5.40 OR = 7.91
CI: CI: CI: CI: 1.8–34.9
1.01–1.04 2.29–9665.45 1.02–28.6
Presentation includes only statistically significant (p < 0.05) variables, and data presented include odds ratio with 95% confidence intervals indicated in parentheses.
Veterinary Record

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Veterinary Record 7 of 10

or suspected peripheral neuro-anatomical localisation idiopathic vestibular disease demonstrated less typical
are derived from the neurological examination. clinical characteristics, such as a perceived progres-
Idiopathic vestibular disease was the most common sion of clinical signs. This finding highlights a poten-
condition in our study population. Although this is in tial limitation of clinical reasoning in which subjec-
agreement with previous reports,9,17 it has also been tive clinical information, provided by pet owners, is
suggested that otitis media interna should be consid- relied on to identify the most likely differential diagno-
ered the most common cause of peripheral vestibu- sis. It is possible that the multifactorial nature of clini-
lar disease in dogs.1,5 Our study included exclusively cal signs in dogs with acute vestibular syndromes (i.e.
cases referred to a specialist hospital, which could affected dogs often demonstrate multiple concurrent
have favoured emergency presentations. It is there- neurological abnormalities) complicates assessment
fore likely that the prevalence of specific diagnoses in of onset and progression for pet owners. It should
our study does not reflect the prevalence of diagnoses further be highlighted that the underlying aetiology
in first opinion practice. Idiopathic vestibular disease and pathogenesis of canine idiopathic vestibular syn-
is indeed a common cause of acute onset intracra- drome are currently unknown. It remains unclear if
nial signs in dogs,33 and veterinary surgeons might this condition represents a single disease entity or
prefer to refer dogs with this clinical presentation for should be considered an umbrella term for different
advanced veterinary care. Despite the acute onset of causes of acute onset of vestibular signs.17 A more
often severe, vestibular signs, idiopathic vestibular dis- insidious and progressive course of clinical signs has
ease has a good prognosis with spontaneous improve- also been reported in a proportion of cats with idio-
ment typically seen after several days.1,4,17 This was pathic vestibular syndrome.39
also illustrated in this study in which an improving Otitis media interna was associated with a lower
clinical course was associated with this condition. bodyweight, younger age, male gender, a clinical his-
Idiopathic vestibular disease was further associated tory of previous otitis externa, concurrent Horner’s
with a higher age, higher bodyweight, the absence of a syndrome and a presumptive peripheral localisation
clinical history of previous otitis externa, the presence of vestibular signs. The association between a previous
of pathological nystagmus, presence of concurrent clinical history of otitis externa and a diagnosis of oti-
facial nerve paresis, absence of Horner’s syndrome tis media is not surprising. There is a close anatomical
and a presumptive peripheral localisation of vestibular relationship between the external, middle and inner
signs. It is well known that this condition occurs com- ear structures and otitis media and interna occurs
monly in older17 large breed dogs and has therefore most commonly as a complication from chronic oti-
also been referred to as ‘idiopathic geriatric vestibu- tis externa.17,40,41 It is therefore possible that dogs
lar disease’.1,4 The high prevalence of pathological jerk with vestibular signs caused by otitis media interna
nystagmus in dogs with idiopathic vestibular disease will also display non-neurological signs, such as head
is in agreement with previous findings.34,35 Pathologi- shaking, ear discharge and pain on opening of the
cal nystagmus is most often seen in the acute stages of mouth or palpation of the bullae.1 It should how-
vestibular disease and is rapidly compensated for by ever be noted that otitis media interna is not always
conscious visual fixation.1,34 It is therefore not surpris- caused by extension of otitis externa, and chronic oti-
ing that this neurological abnormality is statistically tis externa will not necessarily result in otitis media
associated with a disorder characterised by an acute and interna.17,41 This is in agreement with the find-
onset of clinical signs. Although idiopathic vestibular ings of this study in which only two thirds of dogs
disease is characterised by acute onset vestibular signs with otitis media interna had a clinical history of pre-
without other neurological deficits, concurrent facial viously diagnosed otitis externa, and otitis externa was
and vestibular neuropathy of unknown origin has also commonly observed in dogs suffering from other
been reported previously.3,17,35–37 In one study, evalu- causes of vestibular syndrome (Table 1). The recep-
ating the MRI characteristics of dogs with idiopathic tors of the vestibular system are located in the mem-
facial nerve paresis, 70% also had idiopathic vestibu- branous portion of the inner ear, and vestibular signs
lar disease.36 The common observation of concurrent will therefore only occur if structures in the inner ear
facial and vestibular neuropathy can be explained by (i.e. otitis interna) are affected.1,4,5 In this study, the
the close anatomical proximity of both cranial nerves. presence of Horner’s syndrome was associated with
The facial and vestibulocochlear nerves enter the the highest OR to predict a diagnosis of otitis media
petrous part of the temporal bone through the internal interna (Table 2). The middle ear structures have
acoustic meatus and are enclosed in a common dural a close anatomic relationship with the sympathetic
sheath and have the same blood supply.38 The patho- innervation of the eye.5 The three-neuron anatomi-
physiology of idiopathic facial nerve paresis and idio- cal pathway of the sympathetic innervation to the eye
pathic vestibular disease is unclear.17,36 It is further is complex and involves axons that course between
unclear if idiopathic vestibular disease without facial the temporal bone and the tympanic bulla.42 Animals
nerve involvement should be considered a different with disorders affecting the tympanic bulla can there-
disease entity compared to acute vestibular disease of fore also display signs of Horner’s syndrome, includ-
unknown cause with concurrent facial nerve paresis.35 ing miosis, ptosis, enophthalmos and protrusion of the
Although our results are largely in agreement with pre- third eyelid.4,5 Dogs with otitis media interna as the
viously published reports, a proportion of dogs with cause of their vestibular signs were younger than dogs
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8 of 10 Veterinary Record

with other causes of vestibular syndrome. Previous of this study further suggest that positional strabis-
studies have reported that dogs with ear disorders are mus is not commonly seen in dogs with ischaemic
typically between 1 and 5 years old and will only rarely infarcts. Previous studies reporting the clinical signs
be very young or elderly patients.19,43–45 Although oti- and neurological deficits in dogs with suspected ros-
tis media and interna was associated with lower body- tral cerebellar56 and thalamic ischaemic infarcts54
weight, this finding is likely influenced by geographical reported that vestibular signs, consisting of ataxia,
breed distributions and hence the overrepresentation head tilt and nystagmus were commonly observed.
of specific small breed dogs in our study population. In agreement with the results of our study, positional
Cavalier King Charles Spaniels and French bulldogs, strabismus has only rarely been reported in dogs
two breeds predisposed for otitis externa and otitis with cerebellar and thalamic ischaemic infarcts.54,56
media,19,46 were the most commonly included breeds Although positional strabismus can occur with lesions
in this study. The association with male gender is diffi- in any component of the vestibular system,57 it is
cult to explain. Although most studies do not report an possible that lesions in the rostral cerebellum and
association with gender and otitis externa,44,47 some paramedian thalamic region will only have a mini-
studies have suggested a male45,48,49 or female43 pre- mal influence on the development of this neurological
dominance. deficit.
MUO was not associated with multiple specific clin- Brain neoplasia was associated with higher age,
ical characteristics, complicating the use of clinical the presence of a head tilt, multiple cranial nerve
reasoning to recognise vestibular syndrome caused by abnormalities and a central neuro-anatomical local-
this disorder. This diagnosis was only associated with isation. Intracranial neoplasia, such as meningioma,
younger age and the absence of a clinical history of choroid plexus tumors, and gliomas commonly occur
previous otitis externa. This finding illustrates the dif- in the cerebellopontomedullary region or brainstem
ficulty of making a presumptive diagnosis of vestibu- parenchyma.1,26 It is therefore not surprising that
lar syndrome caused by MUO in clinical practice and affected animals demonstrate neurological deficits
also demonstrates the limitations of clinical reason- suggestive for brainstem involvement, such as multi-
ing. MUO is associated with a wide variation in clinical ple cranial nerve deficits. Although a head tilt was also
presentations and signalment of affected animals.24,25 commonly present in dogs with other vestibular disor-
Although MUO was the most common cause of central ders, this clinical sign was only significantly associated
vestibular syndrome in this study, the nature of clini- with a diagnosis of brain neoplasia. This result sug-
cal signs in affected dogs is variable and reflected by gests that a head tilt is commonly observed as the only
the location of lesions in the central nervous system. sign of vestibular dysfunction in dogs with brain neo-
Meningoencephalitis has been associated with young plasia without other vestibular signs.
animals and small breed dogs.24 It should however be This study was limited by its retrospective
noted that every dog breed can be affected, and that up study design and the inclusion of cases without a
to 25% of dogs with MUO are large breed dogs.50 The histopathologically confirmed diagnosis. Although
difficulty of making a reliable presumptive diagno- classification into specific disease categories was
sis of vestibular syndrome caused by MUO in clinical based on advanced diagnostic investigations, specific
practice is however concerning. This condition has a disease categories, such as gliomas and ischaemic
potentially guarded prognosis. Approximately 26–33% cerebrovascular accidents can be difficult to differ-
of dogs with MUO die within the first week of mak- entiate based on MRI alone.58 It should further be
ing a diagnosis, and the remaining dogs often require emphasised that all included dogs were referred to a
lifelong immunosuppressive treatment.51,52 It is there- specialist referral hospital, which might have favoured
fore clear that making an early diagnosis and initiat- emergency and more complex clinical presentations.
ing prompt and appropriate treatment are of major It is therefore likely that the distribution of diagnoses
importance in dogs with MUO. in this study does not represent the distribution
Ischaemic infarct was associated with a higher of canine vestibular disorders in general practice.
age, a peracute or acute onset of clinical signs, the Included dogs did not undergo a standardised diag-
absence of positional strabismus and a central neuro- nostic approach, and the selection of diagnostic tests
anatomical localisation. Previous studies have indeed was based on a combination of presenting clinical
reported that ischaemic infarcts occur most com- characteristics, owner’s and clinician’s preference. The
monly in older animals and that the clinical presen- clinical characteristics of some of the most common
tation is typically characterised by a peracute onset conditions, such as idiopathic vestibular disease and
of severe neurological signs.53–56 Dogs with ischaemic ischaemic infarct have been well reported, and both
infarct and idiopathic vestibular syndrome have a conditions are typically associated with a peracute to
similar onset and progression of clinical signs and acute onset of non-progressive clinical signs.1–4 Sev-
can therefore be difficult to differentiate in veterinary eral dogs in this study were however reported to have
practice.33 The results of this study indicate that obser- atypical clinical characteristics, such as progressive
vation of neurological deficits suggestive for a central clinical signs. This finding illustrates that applying the
neuro-anatomical localization could potentially help principles of clinical reasoning might be limited in
to differentiate dogs with an ischaemic infarct from animals that present with atypical signs of a common
those with idiopathic vestibular disease. The results neurological disorder.
 20427670, 2021, 6, Downloaded from [Link] by CochraneArgentina, Wiley Online Library on [25/08/2023]. See the Terms and Conditions ([Link] on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Veterinary Record 9 of 10

Although this study aimed to identify easy-to- ORCID

recognise clinical characteristics associated with the Nick J. Grapes [Link]
most common causes of canine vestibular syndrome, 5508
this study failed to identify discrete clinical features Steven De Decker [Link]
that would be predictive for one of the most com- 2505-2152
monly identified causes of vestibular syndrome, MUO.
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