TMJ Osteomyelitis (e. cuniculi) or just TMJ & options

Question

Earless Glenna   QUESTION: Hi Dana,

My rescue took in a stray albino bun this summer who had frostbitten ears which washed off with a bath. She was yellow from urine stains and she still has a bit of a stench from the most horrendous urine soaking imaginable. This little escapee also had flystrike and maloccluded incisors and molars. She's since been spayed, abscesses removed, and has regular teeth trims. Her name is Glenna, named after a particularly benevolent adopter. Talk about Les Miserable du lapins!

On her side is a high alpha drive and thus will to live (and dominate!) and overall good attitude. Lately though, her molar trims are becoming more difficult because her mouth won't open very well. She lost some weight but has since put most of it back on by eating a yummy concoction of Critical Care, phytonutrients, crush Oxbow Barley biscuits, and a pinch of faery dust :-) She loves it and is steadily gaining weight back. She can even munch hay if she *really* wants to but prefers her CC slop.

Three vets have seen her now. One is an intern who I am not really willing to accept her opinion. The main one is very experienced but most recently she saw a 'guru' bunny vet who I trust above all of the ones in this area. He thinks she has an e. cuniculi infection of the jaw joint (osteomyelitis), he palpated her entire jaw and felt no abscesses or building infection except in the jaw joint itself. I agree with him although the e.c. titer is still pending. Her bloodwork is pretty normal. She has no fever, she's on metacam and seems pretty happy, she just can't open her mouth. She's also on chloramphenicol and PenG. She's had two radiologists review her head xrays who both have polarizing opinions. It's clear from her xrays that she favors one side when chewing and has muscle atrophy on the other side as a result. In reading about the human treatment for this same condition, a jaw joint flushing is in order for the conservative treatment. Do you know of anyone doing this for rabbits?

The inexperienced vet who wants to rip her jaw open w/out even knowing for sure which tooth might be infected (if at all) had wanted to euthanize her. I refused. She's happy, eating like a horse, loving life. She just can't open her mouth. I am not one to drag a little body through horrendous treatments but I'd like to give her a good life for as long as possible and as long as she cooperates because when she doesn't want to cooperate, she makes it known. I am leary of having some 'dental specialist' look at her who has never anesthetized a rabbit and is not familiar with rabbits at all. What would you do? Do you know if any true bunny vets are doing TMJ flushes? And how I might put them in contact with my vet? Thank you very much for being available to answer questions like this!

ANSWER: Dear Patti,

Wow, what an ordeal little Glenna has survived!  And thanks to you, who helped her so much.

I've never heard of a jaw locking up due to E. cuniculi, but I suppose it could happen.  But does the vet think that there's pus in the jaw?  Or that the parasites are encysted in the innervation supplying the jaw?  I'm not really sure what the thinking is here, so can't really address the suggestion of a TMJ flush.  I've never heard of that procedure, unless it means just opening the jaw and flushing the joint.  But flushing it with what?  If the problem is E. cuniculi, I'm not sure what flushing would do.

But I do agree with you that I wouldn't give up on her.  

Does the vet believe that the jaw paralysis is due to inflammation?  Lack of neuromuscular function in that area?  Is there the possiblity of a stroke (i.e., are other areas on that side of her body affected, too?)?  If there is the suspicion of inflammatory involvement, perhaps a shot of short-acting corticosteroids might help.  But I'm flying blind here.

There's always the possibility that massage and warm compresses could help, too.  Or even acupuncture, if you have a good licensed veterinary acupuncturist available.  

I'm just not familiar enough with the idea of a TMJ flush to advise you on this.  The rabbit TMJ is tiny and delicate, and I'm really not sure how easy it would be to do this.  But if the vet really is confident of success, and nothing else works (I'd think about the steroid injection, right at the site), then...???

But I hope all goes well for her, after all she's been through!

I would be interested to know how it goes, if you have time to share.

Good luck!

Dana


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

QUESTION: Thanks very much for your input, Dana. I will definitely let you know what happens & what I find out. The vet, Dr. Scott Stahl of SEAVS, if I remember accurately, said that he feels her jaw is inflamed and infected possibly w/e.c. He didn't suggest steroids since she had been on metacam for a while before he saw her. I was just reading about TMJ arthrocentesis for humans at http://www.mayoclinic.org/tmj/treatment.html - I didn't discuss it with him. However, I know that he has done things in the past for rabbits that many wouldn't attempt and was successful (removing a broken rabbit hip is one of them). So you have heard of other buns having their jaws lock up like this? If you have, do you know what the cause was for them? Did they sound similar to this?

One vet wanted to anesthetize her every day and stretch and massage the muscles. My understanding is that if it's an infectious agent causing this, massage could spread the infection. So I'm waiting for the e.c. titer results but if it's clear, I will definitely take her to an acupuncturist and we have a bunny one near here. I wonder if that would have the same effect as massage though?

So I was wondering what he might be game to try. Just reading more about human TMJ, her being on CC diet should help those muscles relax. I forgot to mention that I had seen her eating Carefresh quite often for some reason before her jaw froze up. I have switched her to aspen. Don't know why she'd eat that, she has plenty of hay and pellets. Stroke was never mentioned. However, her upper and lower jaw alignment is completely off kilter. Her incisors are trimmed as much as possible, it could just be her TMJ disorder is so bad just from that, I suppose. I will definitely post a follow-up to you. If you happen to hear anything that might be useful for her, please let me know - , Thanks again for your help! Patti

Answer
Dear Patti,

It sounds as if you are aware of all the angles and potential pitfalls, and really have this bad situation under as much control as one could hope.  Poor little bun!  I do wonder if the infection has just messed up her jaw joint so much that it's just freezing up from the inflammation.  Maybe a flush would help. And if it's that or nothing, then I'd let the daring and brave vet give it a shot.

You're right about the massage and spreading the infection, but if it's between that and not being able to open her mouth, I think I might try it--if nothing else works.  If it's really E. cuniculi, though, the infection shouldn't spread.  I'd worry more about it if it were bacterial.

I hope all goes well.  I haven't heard of any other bunnies with locked jaws, and will be glad to hear that this has a happy ending!

Take care, and happy new year!

Dana