American College of Osteopathic Pediatricians

1
Osteopathic Manipulation for Acute Otitis Media
in the Pediatric Population

• American College of Osteopathic Pediatricians
• Kate Ruda Wessell, DO
• Pediatric Resident
• Rainbow Babies and Childrens Hospital
• PGY-1
• January 23, 2011

2
Ear Anatomy
3
Normal TM
4
Ear Anatomy

• Outer 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

5
Otitis Media

• Inflammation of the Middle Ear
• Location between the tympanic membrane and the
  inner ear including eustachian tube
• Most 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, pressure
• Diagnosis
• -visualization of the TM, tympanic
  insufflator

6
Progression of the AOM

• At 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

7
Kids gt Adults. Why?

• The answer is simple.
• Shorter Eustachian Tubes
• -10mm in infancy to 18mm in adulthood
• A 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 year
• 80-90 by age 2 to 3 years

8
Risk Factors for AOM

• Opportunity for Patient Education for the General
  Practitioner
• Breast Feeding for at least 3 months decreases
  risk
• Tobacco smoke and air pollution increases risk
• Pacifier use increases incidence
• Day care attendance raises the incidence

9
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, steroids
• Antibiotics
• OMT
• Tympanostomy Tubes

10
Treatment Antibiotics

• Amoxicillin 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
11
Treatment OMT Techniques

• Galbreath Maneuver first described in 1929 by
  William Otis Galbreath, DO
• Galbreath 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

12
Specifics of the Galbreath Maneuver

• The pediatric patient should be lying his or her
  back
• The 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 patients 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.

13
Galbreath Technique
14
Auricular Drainage Technique

• This technique also requires the pediatric
  patient to lie on his or her back
• The physician forms a V by separating their
  middle and ring fingers on the hand that is
  closer to the childs 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
  childs 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.

15
Auricular Drainage
16
Treatment Tympanostomy Tubes

• Generally 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

17
Evidenced Based Medicine

• Case Study 14 mo. old female with previous
  history of AOM txd 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, childs
  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

18
Evidenced Based Medicine

• Study DesignPilot cohort study with 1 year
  posttreatment follow up
• SubjectsVolunteer sample of pediatric patients
  ranging in age from 7mo to 3 yrs with a history
  of recurrent otitis media (n8)
• InterventionFor 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.

19
Evidenced Based Medicine

• ConclusionThe 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
20
Hands On Time to Practice

• Landmarks
• Sympathetic Innervation
• Order of Treatment to maximize technique
  efficacy
• -Stretching
• -Myofascial Release of Restrictions/Choke Points
• -Galbreath Technique
• -Auricular Drainage
• -Lymphatic Pump

21
1.
2.
LANDMARKS

1. Locate the Ear of Your Patient
2. Imagine the Inner Ear Anatomy
3. Imagine the Lymphatic System Surrounding the Ear
   Anatomy

3.
22
Innervation Table
23
STRETCHING
24
MYOFASCIAL RELEASE
25
GALBREATH TECHNIQUE
26
AURICULAR DRAINAGE
27
LYMPHATIC PUMP
28
Question 1

• What is the most common bacterial cause of AOM?
• Haemophilus Influenza
• Streptococcus pneumonia
• Moraxella catarrhalis
• Pseudomonas aeruginosa

29
Question 2

• What is the most sensitive diagnostic tool for
  diagnosing AOM?
• Visualization of TM with otoscope
• Pneumatic otoscopy
• A child tugging at their ears
• Fever and a child tugging at their ears

30
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

31
Summary

• Ear Anatomy
• Otitis Media causes, diagnosis, treatment
• OMT Techniques
• Evidenced Based Medicine
• Potential 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

32
SPECIAL THANKS TO MY PATIENTS HAYDEN AND MAYCEE
33
References

• Acess 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

34
Certificate of Completion

• I, _________________________, successfully
  completed the Pediatric OMT Module on __ __ 20__
• Signatures
• Pediatric Resident ____________________
• Pediatric Residency Director____________
• ( Please print and give to program director.)