Face and Head Problems

Masticatory myopathy possible

Question: Dear Dr. Mike -

We have a 13 year old lab/Queensland Heeler mix (apprx. 60 lbs) who, from all the research we have done, seems to have the symptoms of craniomandibular osteopathy. For his age, he is in extremely good shape and health. Happy, shiny coat, overall in good shape, except for his arthritis, which we have all adapted to. His name is Puppy Dog.

Recently, Pup has developed an exaggerated "cheek bone" (where mandibular goes up into the cranium) which has enlarged and now seems to protrude out from his skull, while at the same time the soft tissue above that bone and behind his eye (this would be the front top right quarter of his head), is now a cavity. That soft tissue has shrunken or atrophied, leaving a depression over his eye, and over the cheek bone. There is no enlargement of the lower jaw that we can see and no change in the left side of his head. The condition is localized to the upper right quarter of his head. He may not have CMO, but we think that's what it is. Except for one small problem: athough his name is "Puppy," he is not a pup. He is 13 years old. And all info we can find says that you will find this in puppies. Our vet doesn't know what the problem is, but says since the dog seems to be in no pain, not to worry about it.

With all that said, our concern now is what this exaggerated cheekbone/depression of soft tissue thin is and would like to know what your thoughts on this might be.

Question One: Are we correct? Does our dog have CMO? Is this situation serious for our dog?

Second Question: Have you any thoughts about possible over supplementation contributing to this condition? (See #7 below)

Third Question: Will incurring the expense of an MRI be ultimately helpful to our dog? We would not want to get into experimental or "high risk" surgeries with him. We are focused on giving him a joyful and painfree experience in his later years, not just more years...

Fourth Question: What can we expect in the future if left untreated? We are concerned about undetectable headaches, and pain for our dog.

Fifth Question: Can you recommend a specialist in the Dallas area who might help us?

Below is an itemized list of symptoms and particulars:

1. First noticed about 2 months ago

2. Over the last two months, depression has been getting deeper and exaggeration of cheekbone more prominent.

3. Pup does not seem to be in pain over it. (we are concerned about future headaches if the bone continues to grow)

4. The condition is apparent only on the right side of his head, and no growth of lower jaw that we can tell.

5. About a month ago, before it started getting really bad, it reminded us of what a dig will start looking like when it gets really old (standard "old dog" bony head), but now it's gotten worse, so "just getting old" is out.

6. Pup has a history of arthritis for at least 8 years and was taken off Prednidone and Rymadil and put on supplements about 5 years ago. They seem to be working just fine.

7. He is on the following supplements for his arthritis, low grade hypothyroidism and we just discovered from our vet that our dog has some spinal nerve degeneration (flip back foot backwards and he doesn't notice it): Ligaplex II, GlycoFlex Plus*, Omega-3 Capsules, Acidophilus, Co-Q10, Missing Link, Thyroid Tabs*, Thytrophin*, Senaplex* and Cholodin*. He is on a home made diet, as described in Dr. Pitcairn's book.

8. We first noticed these symptoms right after we started giving Pup the *'d supplements above. (Note that this may or may not be related to his condition.)

It seems that the condition came up rather quickly. Has developed from "non-existent" to "very obvious" in less than 3 months. Thus far, continues to develop at that rather fast rate. It looks as if (we hope) it may be slowing down but can't really tell yet.

We literally live a block away from the Dallas Veterinary MRI clinic but... the last time our vet referred us there, we did a $500 sonogram for bladder cancer and found out that Pup was fine, and the test done by our vet was probably faulty, so... we are hesitant to spend money on an MRI, especially if we won't learn anything which might be helpful to our dog.

We love your web site and it's clear that you are a concerned and decent person. We look forward to hearing from you.

Thanks for all your help. Rich and Linda

Rich and Linda-

I don't think that craniomandibular osteopathy is very likely at this age. The list of possible differentials (possible diseases) for the symptoms seen would depend some on the appearance of X-rays of the area. However, I would worry most about a myopathy or neuropathy with the symptoms you are describing. Masticatory myopathy affects the muscles of mastication (chewing), leading to atrophy of the muscles. This causes the appearance of the skull to change dramatically and for bony prominances to occur where none were previously visible. The amount of muscle loss can be amazing in these cases as the muscles are very thick over the bone, usually. It can occur on one side, or both sides. It is not too unusual for it to occur on one side and then later to occur on the other side, too. This is thought to be an immune mediated disease in most cases and it will often respond to therapy with medications that suppress the immune system. In some cases this can eventually lead to problems with opening the mouth, so it is best to try to treat it, if possible, I think. Nerve damage can also cause muscle atrophy but is less responsive to therapy. Other possibilities, such as cancer seem possible, as well. In any case, it does seem best to either get a second opinion locally or see a specialist.

It should be possible to find an internal medicine specialist or veterinary neurologist in Dallas, but I am not familiar enough with the specialists there to be able to make any specific recommendations. If your vet doesn't know what to do, he or she should be willing to arrange for a referral to a specialist for you.

I would be surprised if an MRI or CT scan was necessary to diagnose this condition but wouldn't be able to rule out that possibility. The first step is to try to rule out a myopathy, though. If that isn't the problem, then it would be reasonable to consider looking for other problems and if necessary to find them, doing tests like an MRI or CT scan.

I can't really help much with the possibility of a dietary change leading to this problem. I am not aware of any documentation of that occurring in dogs but I couldn't absolutely rule it out as a possibility, either.

Mike Richards, DVM 6/5/2001

Head shaking - Doberman

Question:Hi Dr. Richards,

My 2 year old doberman has been shaking her head and ears for the past (we think) three weeks. When it started we took her to the vet and they said it was because her ears were dirty and needed a good cleaning. The cleaning didn't seem to help so we took her back a week later for another cleaning and I suggested it might be ear mites, although we saw no sign of that. She has been on the ear mite medication and we haven't noticed any difference. Her ears don't look red or infected and the vet said he didn't notice anything else wrong with them.

We lost our older doberman to cardio a month ago and since then (probably because of lonliness) the pup has been put on clomipramine for a lick granuloma. If the head shaking started around the same time and this was just a nervous habit wouldn't the clomipramine have helped this the same way it stopped her from licking?

The head shaking could have even started before we lost the other dog (we don't think so though) but we were so caught up in caring for her we might not have even noticed the pup doing this.

Can you thing of anything else that could be wrong with her ears?

Thanks Sheilah

Answer: Sheilah-

As you seem to be aware, already, it would really help a lot to know if the head shaking started before or after the administration of clomipramine (Clomicalm Rx). It would not surprise me if the head shaking was a reaction to the medication, but it is probably more likely that it is not. The only way I know of to find out is to stop the administration of clomipramine. Your vet can help you decide if that is a good idea, based on the response to treatment so far, the severity of the lick granuloma and the other signs of separation anxiety.

In my practice area, head shaking is a frequent side effect of allergies, fleas, mosquito bites and fly bites. Allergies can be inhalant allergies to pollens, etc. (atopy), food allergies, or flea or mosquito bite allergies (worse reaction than just getting bitten). Some dogs have immune mediated diseases that make their ears itchy. Occasionally a young dog will have head shaking as an early sign of demodectic mange infestation. Sarcoptic mange mite infection also can lead to head shaking.

In the case of atopy, the head shaking may be the result of itchiness or it may be the result of inflammation of the respiratory tract and eustachian tube leading to problems equalizing the pressure in the middle ears or to fluid accumulation in the middle ears. Antihistamines may help relieve the itchiness and sometimes help with the respiratory signs, as well. You might want to ask your vet about this, too.

Food allergies usually cause pretty severe inflammation of the external ear, at least in the few cases we have been able to confirm. For this reason, I would tend to think these are a little less likely if your vet wasn't seeing a lot of visible inflammation in the ears. It is possible that our experience doesn't match the general experience in these cases, though.

I find ear mites pretty hard to see now that I have gotten older. I think that really early ear mite infections are hard to find but still pretty itchy, so a recheck is not a bad idea, if for no other reason than to check for ear mites again.

Good luck with this.

Mike Richards, DVM 4/25/2000

Head shaking

Question: Dr Mike, Our dog Crissy is a 60 pound, shepherd mix, estimated to be around 6 or 7 years old. Thankfully she is healthy according to our vet. I had notice a good amount of sudden head shaking...with no other signs such as pawing or starching her ears. When we took her in for her annual check, we told our vet of our observation and he did inspect her ears and found nothing remarkable. His explanation was "dogs do that". This behavior continues and seems more frequent, but again no other signs of concern. I reviewed your site and was unable to find anything that would explain this behavior. Can you help?

Thanks, Pat

Answer: Pat,

Last year I read someone's observation that many dogs that have ear infections, ear inflammation or that shake their head in the absence of other clinical signs have middle ear pressure equalization problems. This occurs in people with allergies so I don't see any reason why it couldn't also occur in dogs. I can't remember where I read this and have not been able to find the literature reference to give proper credit.

If this theory is correct, it may help to use an antihistamine to aid in controlling this problem. Clemastine (Tavist tm) is the antihistamine that seems to work most often in dogs but it is OK to try others. The dosage for clemastine for a 60 lb. dog would be one tablet (1.34mg) twice a day.

If antihistamines don't help it would still be a good idea to pay special attention to Crissy's ears because ear shaking does occur with allergies in dogs and secondary bacterial or yeast infections are not uncommon if allergies are present. Catching infections early would be helpful. If you suddenly find a build up of wax or exudate in the ear, if it becomes hot to the touch or if it seems to pain Crissy when you touch her ears, it would be a good idea to take her to your vet for a recheck.

Hope this helps some.

Mike Richards, DVM 2/10/2000