American College of Osteopathic Pediatricians

Kate Ruda Wessell, DOPediatric Resident Rainbow Babies and Children’s

HospitalPGY-1

January 23, 2011

Osteopathic Manipulation for Acute Otitis Media in the Pediatric Population

Ear Anatomy

Normal TM

Ear AnatomyOuter Ear: Pinna, External Auditory Meatus,

Outside of Tympanic Membrane

Middle Ear: Inside of Tympanic Membrane, 3 ossicles; Malleus, incus, and stapes and Eustachian Tube

Inner Ear: Cochlea, vestibule, and semi-circular canals

Otitis Media Inflammation of the Middle EarLocation between the tympanic membrane and the

inner ear including eustachian tubeMost frequent diagnosis in sick children in U.S.Viral, bacterial, fungal: -most often viral and self-limited -bacterial causes include: #1 Streptococcus

pneumoniae, nontypeable Haemophilus influenzae, and Moraxella catarrhalis

Signs/Symptoms -discomfort, “popping”, pressureDiagnosis: -visualization of the TM, tympanic insufflator

Progression of the AOMAt an anatomic level, the tissues surrounding the

Eustachian tube swell due to an URI, allergies, or dysfunction of the tubes. The Eustachian tube remains blocked most of the time. The air present in the middle ear is slowly absorbed into the surrounding tissues.

A strong negative pressure creates a vacuum in the middle ear, and eventually the vacuum reaches a point where fluid from the surrounding tissues accumulates in the middle ear. The fluid may become infected by dormant bacteria behind the TM

Kids > Adults. Why?

The answer is simple.Shorter Eustachian Tubes-10mm in infancy to 18mm in adulthoodA more horizontal angle of the Eustachian Tubes-10 degrees to horizontal in infancy to 45 degrees in adulthood

60-80% of infants have at least 1 episode of AOM by age 1 year80-90% by age 2 to 3 years

Risk Factors for AOMOpportunity for Patient Education for the

General PractitionerBreast Feeding for at least 3 months

decreases riskTobacco smoke and air pollution increases

riskPacifier use increases incidenceDay care attendance raises the incidence

Otitis Media Treatments

Observation and Self-Limitation: based on diagnostic certainty, age, illness severity, and assurance of follow-up

Pain Remedies: topical agents (Auralgan), oral agents

Antihistamines, decongestants, steroidsAntibioticsOMTTympanostomy Tubes

Treatment: AntibioticsAmoxicillin 80-90 mg/kg/day divided BID for 5-7

days for episodes in most children 6 yrs of age or older

Younger children and children with underlying medical conditions, craniofacial abnormalities, chronic or recurrent otitis media, or perforatoin of the tympanic membrane should receive a 10 day course

Persistent middle ear effusion for 2-3 months after therapy for AOM is expected and does not require routine retreatment

If effusion lasts greater than 3 months, tx for 10-14 days may be considered

American Academy of Pediatrics “Red Book” 2009 Report of the Committee of Infectious Disease

Treatment: OMT TechniquesGalbreath Maneuver first described in 1929

by William Otis Galbreath, DOGalbreath Maneuver: simple mandibular

manipulation, the eustachian tube is made to open and close in a "pumping action" that allows the ear to drain accumulated fluid more effectively

Auricular Drainage Technique

Specifics of the Galbreath ManeuverThe pediatric patient should be lying his or her backThe physician places one hand on the chin, with

thumb and forefinger resting along the lower jawbone. The other hand is placed on the forehead to hold the patient’s head in place.

As the child opens his/her mouth, the physician gently moves the lower jaw to the side away from the ear with AOM and holds it there for three to five seconds before releasing the jaw. The physician then repeats this maneuver three times.

Galbreath Technique

Auricular Drainage TechniqueThis technique also requires the pediatric patient to

lie on his or her backThe 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.

Auricular Drainage

Treatment: Tympanostomy TubesGenerally considered when patients have

more than 3 episodes of acute otitis media in 6 month or 4 in a year associated with an effusion

Reduces recurrence rates in the 6 months after placement

Evidenced Based MedicineCase Study: 14 mo. old female with previous history of

AOM tx’d with abx of amox 10 day course, and repeat abx for incomplete resolution. She presents with temp 102.8, pulse 118, RR 24, nose and pharynx erythematous and edematous. Right TM bulging, nonmovable with pneumatic otoscopy. Script for abx written and Galbreath technique in office. Within 30min of tx, child’s temp reduced to 99.2, and PE revealed decrease in erythema and edema of TM. Patient completed course of abx and Galbreath Technique 2 x daily. Whenever symptoms revisited; mother performed Galbreath, and pt. was not placed on abx since.

JAOA Vol 100 No 10 October 2000 Pratt-Harrington Review Article

Evidenced Based MedicineStudy Design:Pilot cohort study with 1 year

posttreatment follow upSubjects:Volunteer sample of pediatric patients ranging

in age from 7mo to 3 yrs with a history of recurrent otitis media (n=8)

Intervention:For 3 weeks all subjects received weekly osteopathic structural exams and OMT; concurrently with trandional medical management.

Results: 5 (62.5%) had no recurrence of symptoms. One had a bulging TM, one had 4 more episodes of O.M., and one underwent surgery after recurrence at 6 weeks posttreatment. Closer analysis of the posttreatment course of the last two subjects indicates that there may have been a clinically significant decrease in morbidity for a period of time after intervention.

Evidenced Based MedicineConclusion:The study indicates that OMT may

change the progression of recurrent AOM. There is a need for additional research in this area.

JAOA Vol 106 No 06 June 2006 Osteopathic Evaluation and Manipulative Treatment in Reducing the Morbidity of Otitis Media: A pilot study. Degenhardt, Kuchera pgs 327-334

Hands On: Time to PracticeLandmarksSympathetic InnervationOrder of Treatment to maximize technique

efficacy:-Stretching-Myofascial Release of Restrictions/Choke

Points-Galbreath Technique-Auricular Drainage-Lymphatic Pump

1. Locate the Ear of Your Patient

2. Imagine the Inner Ear Anatomy

3. Imagine the Lymphatic System Surrounding the Ear Anatomy

1.

2.

3.

LANDMARKS

Organ/System Parasympathetic Sympathetic Ant. Chapman's

Post. Chapman's

EENT Cr Nerves (III, VII, IX, X)

T1-T4 T1-4, 2nd ICS

SuboccipitalHeart Vagus (CN X) T1-T4 T1-4 on L,

T2-3T3 sp process

Respiratory Vagus (CN X) T2-T7 3rd & 4th ICS T3-5 sp process

Esophagus Vagus (CN X) T2-T8 --- ---Foregut Vagus (CN X) T5-T9 (Greater Splanchnic) --- ---Stomach Vagus (CN X) T5-T9 (Greater Splanchnic) 5th-6th ICS on

LT6-7 on L

Liver Vagus (CN X) T5-T9 (Greater Splanchnic) Rib 5 on R T5-6Gallbladder Vagus (CN X) T5-T9 (Greater Splanchnic) Rib 6 on R T6Spleen Vagus (CN X) T5-T9 (Greater Splanchnic) Rib 7 on L T7Pancreas Vagus (CN X) T5-T9 (Greater Splanchnic),

T9-T12 (Lesser Splanchnic)Rib 7 on R T7

Midgut Vagus (CN X) Thoracic Splanchnics (Lesser)

--- ---Small Intestine Vagus (CN X) T9-T11 (Lesser Splanchnic) Ribs 9-11 T8-10Appendix    T12 Tip of 12th

RibT11-12 on R

Hindgut Pelvic Splanchnics (S2-4)

Lumbar (Least) Splanchnics --- ---Ascending Colon  Vagus (CN X) T9-T11 (Lesser Splanchnic) R Femur @

hipT10-11

Transverse Colon  Vagus (CN X) T9-T11 (Lesser Splanchnic) Near Knees ---Descending Colon Pelvic Splanchnic

(S2-4)Least Splanchnic L Femur @

hipT12-L2

Colon & Rectum Pelvic Splanchnics (S2-4)

T8-L2 --- ---

STRETCHING

MYOFASCIAL RELEASE

GALBREATH TECHNIQUE

AURICULAR DRAINAGE

LYMPHATIC PUMP

Question 1: What is the most common bacterial cause of

AOM?

A. Haemophilus InfluenzaB. Streptococcus pneumoniaC. Moraxella catarrhalisD. Pseudomonas aeruginosa

Question 2: What is the most sensitive diagnostic tool

for diagnosing AOM?

A. Visualization of TM with otoscopeB. Pneumatic otoscopyC. A child tugging at their earsD. Fever and a child tugging at their ears

Question 3:What is the appropriate order to complete OMT

treatments to increase the efficacy of OMT to treat AOM?

A. Galbreath Technique, Stretching, Restriction Reduction, Auricular Drainage, Lymphatic Pump

B. Auricular Drainage, Galbreath Technique, Stretching, Restriction Reduction

C. Stretching, Restriction Reduction, Galbreath Technique, Auricular Drainage, Lymphatic Pump

D. Lymphatic Pump, Galbreath Technique, Auricular Drainage, Stretching, Restriction Reduction

SummaryEar AnatomyOtitis Media: causes, diagnosis, treatmentOMT TechniquesEvidenced Based MedicinePotential Areas to Continue to Develop

Osteopathic Principles and Practice regarding Otitis Media

-blinded studies with larger cohorts are necessary to determine the effectiveness of this tx modality in pediatric patients

SPECIAL THANKS TO MY PATIENTS: HAYDEN AND MAYCEE

ReferencesAcess Medicine: Current Medical Diagnosis and Treatment: Chapter 8. Ear, Nose, and

Throat Disorders. “Acute Otitis Media”

Gunasekera H et al. Management of children with otitis media: a summary of evidence from recent systematic reviews. J Pediatric Child Health. 2009 Oct; 45 (10): 554-62.

JAOA Vol 100. No 10. October 2000. “Galbreath Technique: a manipulative treatment for Otitis Media Revisited” pgs 635-639.

JAOA Vol 106 No 06 June 2006. “Osteopathic Evaluation and Manipulative Treatment in Reducing the Morbidity of Otitis Media: A pilot study.” Degenhardt, Kuchera pgs 327-334

Red Book: 2009 Report of the Committee on Infectious Disease. American Academy of Pediatrics “Otitis Media” page 741.

UpToDate: Acute Otitis Media in Children

I, _________________________, successfully completed the Pediatric OMT Module on __ __ 20__

Signatures:Pediatric Resident ____________________Pediatric Residency Director____________

( Please print and give to program director.)