long-term treatment for head tilt

Question
QUESTION: Hi Dr. Krempels,

I have an 8 year old rabbit who came down with head tilt in July of this year. She has an ear infection, and through a CT scan done in October, we know that both of her bullas are filled with pus that will not drain out without surgery. The scan also found a small build-up in her nose. After a difficult decision, we decided not to do the surgery as it seemed too invasive. We opted instead to give her what our vet called "palliative care" at home, which is 0.4mL of meloxicam per day, and shots of penicillin every 3 days.
The good news is, we have been giving our bunny this treatment at home for over 4 months and she is doing MUCH better. Her head is still tilted, but not as much as before, and she pretty much lives a normal life--her appetite is amazing, she runs around outside her cage, she cleans herself, loves to be pet, etc. While she is not "back to normal" she seems perfectly happy and is definitely the best she has been since July.

The question I have for you is: what do you know about the long-term treatment of head tilt when it cannot be actually cured? Should we be giving her meloxicam and penicillin forever? The truth is, after seeing the results of the CT scan, I thought we would see her slowly declining, but we are actually seeing the opposite. As you can imagine, my bunny is really tough and definitely has not given up, but what can we expect in the months to come? Any insights about long-term treatment and care would be much appreciated. Thank you!

PS. As a side note, our first vet unfortunately did not know about Marcy Rosenfield Moore's bicillin treatment--we learned about it later through researching online, and our new vet has said this treatment cannot help at this point because of the bullas. Maybe if we had known about it at the beginning we wouldn't have gotten to this point...

ANSWER: Dear Miko,

I'm not convinced that long-term dual-acting penicillin will not gradually clear your bunny's bullae.  The antibiotic will not get into the middle of the bulla, but there is vascularization at the edges, and it's possible that gradually, as the drug kills the outlying bacteria, the pus could liquefy and be absorbed.  We've seen this happen with soft tissue abscesses, which also have poor vascularization.  But it can take a while.

The proof is in the pudding:  your bunny is getting better.  So there might well be some gradual improvemnent.  I would keep him on the metacam (not a high dose, as this could be rough on his kidneys, long term) and dual-acting Pen-G/Benzathine for as long as it takes.  It could be a year.  We've had bunnies on it that long, and it does help keep things under control.  Sometimes it can effect a cure.

I hope that's true for your bunny!

Dana

---------- FOLLOW-UP ----------

QUESTION: Hi Dana,

Thanks so much for your response. I'm happy to have some reassurance that we can continue with this treatment. It really seems to be working, but neither of the vets we've been to had any hope she could recover. I'm realistic that she may eventually succumb to this, but happy to have some hope too! She has certainly defied everyone's expectations :)

Can I just ask- when you say "as long as it takes" do you mean until her head stops tilting? Is that how we would know she is better?

Again, many thanks. We're all lucky to benefit from your expertise!

Answer
Dear Miko,

We've had numerous head tilt bunnies who lived long, full lives, though sometimes with a small, residual tilt to the head.  It doesn't seem to bother them:  they adjust and look kind of cute, looking up at you from one side.  It is not a given that she will succumb to this problem.  

And by "as long as it takes," I mean until she is stabilized and is improving to a plateau.

There are physical therapy methods you can use to help her straighten up, such as massage, acupuncture, and exercise in large areas where she doesn't have to run in circles.  A new, interesting place often stimulates the bunny to stretch the neck and straighten out to see things better.

You can read more about treatment and find a physical therapy link in this article:

http://www.bio.miami.edu/hare/tilt.html

No need to think you will lose your bunny to this problem, which is quite manageable.  

Hope this helps.

Dana