Osteopathic Approach to Otitis Media (Ferrill, Oct 19) plus lab slides (Oct 20)

Question 1

Eustachian Tube physiology

Answer 1

Functions

• Equilibrates pressures
• – Aids in sound transmission
• Prevents reflux
• Drains fluids

Collapsed at rest

Respiratory epithelium

Question 2

infant vs adult eustachian tube

Answer 2

Infant:
More pliable, less cartilaginous
Horizontal orientation

Increased incidence of reflux

Adult:
Cartilaginous
More vertical orientation

Question 3

Eustachian Tube Dysfunction

Answer 3

A common denominator in otitis media spectrum of disease. ET function can be disturbed by:

Abnormal patency
- Secondary to flexible tube

Extrinsic obstruction

• Adenoids or tumor
• Musculoskeletal somatic dysfunction

Intrinsic obstruction
- Luminal narrowing due to swelling, edema or hypertrophy, or congenital narrowing

Question 4

Tensor veli palatini

Answer 4

is a key muscle in ET function and key player in children with ET dysfunction.
When functioning normally, the TVP contracts while opening the pharyngeal space or swallowing. This opens the ET to equalize pressure in the middle ear and allow passage of fluid from the middle ear into the pharynx (think of when you pop your ears while flying. The muscle you are using to do that is the TVP).
When the TVP becomes hypertonic it can affect the ET in one of two ways: clamp it shut, or keep it open.
In young children the ET is very pliable. In this situation, the ET will collapse when the TVP is hypertonic.
As we age, the ET obtains a greater amount of cartilage and becomes less compliant. So in younger children and adults, the hypertonic TVP will cause the ET to remain open. This is called a patulous ET.
Both of these situations are termed “Eustachian Tube Dysfunction”

Question 5

The middle ear is essentially a flask,

Answer 5

the Eustachian tube is the neck

Question 6

in the flask and neck analogy, the TVP (tensor velli palatini) is

Answer 6

a stopper for the flask

Question 7

TVP is also responsible for

Answer 7

draining the eustachian tube

Question 8

Muscular dysfunction and the ET

Answer 8

Tensor Veli Palatini:
Spasm will cause a patulous tube in the adult
Spasm will cause distortion and extrinsic obstruction in the child

Medial Pterygoid:
Contraction causes compression of the tube

Question 9

children vs adults: skull and EAC

Answer 9

As the child grows, the temporal bone undergoes tremendous growth, with the mastoid process becoming more prominent. This changes the orientation of the EAC from one that is primarily facing inferiorly to one that is more laterally oriented. This is why in children you must change the angle of your otoscope, viewing superiorly, to be able to appreciate the tympanic membrane.

Question 10

inferior aspect of the skull: infant vs adult

Answer 10

The bones of the infant skull are still very membranous with islands of boney growth centers. This changes the way we think of, and approach osteopathic manipulation in the infant and child. Again, note the inferior orientation of the tympanic membrane in the infant skull. It is not yet enveloped in bone as in the adult skull.

Question 11

location of eustachian tube in infant/ young child

Answer 11

it is directly inferior to the junction between the petrous temporal bone and the SBS. Any distortion in the movement of the cranial base could affect the function of the eustachian tube.

Question 12

The role of OMT

Answer 12

Primary desired outcomes:
Improve lymphatic drainage from the middle ear
Decrease effusion from the middle ear
Improve function of the Eustachian tube
Improve cranial base and temporal bone motion
Decrease pain

Secondary desired outcomes:
Decrease necessary surgeries
Decrease hearing challenges

Question 13

targeting lymphatic flow in otitis media

Answer 13

Target transitional areas:
Major diaphragms of the body
Areas of lymphatic drainage

Question 14

Complete Osteopathic treatment

Answer 14

Osteopathic Manipulative Treatment
- Biomechanical: 
Aimed at getting things moving
Cranial base mechanics
Upper cervical mechanics

• Respiratory/circulatory
  Aimed at improving lymphatic flow and fluid drainage from eustachian tube and supporting lymphatics
  — Anterior cervical musculature and fascia
  — Diaphragms
  — Thoracic outlet
  — Galbreath
  — Auricular drainage

AND standard medical care

• Pain medications and antibiotics as indicated
• Environmental factors

Question 15

Typical otitis media “protocol”

Answer 15

Sacroiliac joints
Thoracolumbar junction
- Myofascial release

Ribs

• Myofascial release
• Balanced ligamentous tension (BLT)

Thoracic inlet
- Myofascial release

Cervical spine
- BLT

Craniocervical junction
- Suboccipital inhibition

Venous sinus drainage

Occipital decompression

Sphenobasilar symphysis (SBS) decompression

Question 16

tympanogram after OMT

Answer 16

restoration of regularity and peak in the post-OMT tympanogram. It is not perfect, but is far more functional than before the OMT.

Question 17

What parents can do at home

Answer 17

Galbreath Technique
Purpose – to increase blood flow through the pterygoid plexus of veins and lymphatics, drainage of the Eustachian tube, stretching of the peri-pharyngeal muscles (tensor veli palatini) and fascia

• Patient supine (or seated in a lap while reading, etc)
• Affected side down (or away from treating hand)
• Grasp mandible of affected side
• Draw mandible downward and transversely with mild force for 3-5 seconds, repeating for 30-60 seconds

Question 18

Auricular drainage

Answer 18

Pt can be seated or supine
The physician forms a “V” by separating their middle and ring fingers on the hand that is closer to the child’s feet.
Placing the ear with AOM in the base of this “V” the physician places his or her other hand on the opposite side of the child’s head to provide support.
The physician then gently but firmly massages the infected ear in a clockwise motion, then reverses direction, massaging the infected ear in a counter-clockwise direction.

Question 19

Cervical FPR

Answer 19

1. The child is seated with the physician to the side for best control of the head.
2. One hand is used to monitor tissue response to treatment at the level of the dysfunctional segment(s). The other hand is placed on the head.
3. The child’s head is gently placed in relative flexion until the cervical spine is in a postural neutral position.
4. A gradual and gentle axial compression is applied until there is a softening of the tissues just under the monitoring hand. Force used should be no more than 2.5kg.
5. While maintaining the axial compression, the segment monitored is then brought into is position of ease, or into the position of diagnosis. For example, if the diagnosis was C4FRSr, than C4 would be gently brought into a flexion, sidebending and rotation to the right using the head as well as translational motion of the monitoring hand.
6. This position is held for 3-5 seconds and then released and the area is re-assessed. This procedure can be reapplied as many times and the child allows.

Question 20

Thoracic inlet MFR

Answer 20

. The child is seated or standing with the physician behind them.

2. The physician contacts the first and second ribs and possibly the manubrium anteriorly, and the costotransverse junction of T1 posteriorly. The focus of treatment is on the fascial connections of the thoracic inlet.
3. The area is engaged by gently lifting superiorly. Balance is sought by bringing the area into ease or bind through engaging flexion/extension, sidebending and rotational barriers.
4. When the breath is easily felt coming through the tissues, the position is held until a correction of the mechanical strain occurs or improvement in tissue motion is noted.

Question 21

Teaching the parents

Answer 21

Upper thoracic lymphatic drainage
Galbreath
Auricular drainage
Lots of water, preferably warm