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American College of Osteopathic Pediatricians
Kate Ruda Wessell, DOPediatric Resident
Rainbow Babies and Children’s Hospital
PGY-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 consideredAmerican 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
Suboccipital
Heart Vagus (CN X) T1-T4 T1-4 on L, T2-3
T3 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 L
T6-7 on L
Liver Vagus (CN X) T5-T9 (Greater Splanchnic) Rib 5 on R T5-6
Gallbladder Vagus (CN X) T5-T9 (Greater Splanchnic) Rib 6 on R T6
Spleen Vagus (CN X) T5-T9 (Greater Splanchnic) Rib 7 on L T7
Pancreas 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 T8-10
Appendix T12 Tip of 12th Rib
T11-12 on R
Hindgut Pelvic Splanchnics (S2-4)
Lumbar (Least) Splanchnics --- ---
Ascending Colon Vagus (CN X) T9-T11 (Lesser Splanchnic) R Femur @ hip
T10-11
Transverse Colon Vagus (CN X) T9-T11 (Lesser Splanchnic) Near Knees ---
Descending Colon Pelvic Splanchnic (S2-4)
Least Splanchnic L Femur @ hip
T12-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.)