URI: SINUSITIS AND OTITIS MEDIA
Case Presentation
A 29 year old female presents to your office complaining of headache, face hurting,
stuffy nose, cough, general malaise, and fever (101o) times 3 days. Patient currently
complains of large amounts of yellow and green mucous when she blows her nose.
She states that she suffers from seasonal allergies and they were really bothering her
for a few weeks before this happened. She took OTC Pseudoephedrine and
diphenhydramine daily for relief of allergy symptoms. She also took some OTC flu
medication, but she can’t remember what it was.
Differential Diagnosis
Viral URI
Allergic Rhinitis
Sinusitis------ correct diagnosis
Kartagener’s Syndrome
HIV Infection
Cystic Fibrosis
Etc...
Inflammation of mucosa (due to allergies, infection, etc.)  Sinusitis Inc. mucous
production and decrease ciliary fxn
Treatment Considerations
Pharmacologic
Mucoactive agents ex. guafenasin
Antibiotics
Decongestants
OMT
Sympathetics ex. Kirksville
Parasympathetics
Lymphatics ex. To restrict fascial restrictions in the neck
Respiratory Mechanics
Hydration - Drink warm, clear fluids - to thin out secretions
Osteopathic Considerations
Cranial
Fronto-ethmoidal; Facial bones
Improve pumping action of vomer
Venous Sinus Release
Cervicals - Superior sympathetic ganglion in close proximity to OA
Thorax
Sympathetics
Lymphatic return
Sibson’s Fascia
Pterygoid mm.
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Sphenopalantine ganglion
Chapman’s points
The negative thoracic pressure created during inspiration moves the venous blood and
lymph.
Sinus Anatomy
Four pair of sinuses are found in the face and head.
Frontal
Maxillary
Sphenoid
Ethmoid
All drain into the nose
Lined with respiratory epithelium (ciliated)
Susceptible to infection
GOAL - Promote Mucociliary Clearance
Eustachian tube goes into nasal cavity; it is more horizontal in children therefore
more susceptible to otitis media; as you age, it gets more vertical
Ostia - points of drainage of the sinuses.
Maxillary and Spenoidal ostia are located near the roof instead of the floor of the
sinus.When mucous gets thick it is difficult for the cilia to move it up to the opening.
Ostia can be obstructed by :
engorgement of the nasal mucosa
hypertrophy or hyperplasia
Bountifully supplied sensory nerve endings
Point this out on slide.
Anterior pattern - Ethmoid, frontal, maxillary
Into middle turbinate
Posterior pattern - ethmoid, sphenoid
sphenoethmoid recess
Sympathetic Innervation
T1 - T4
Ascend to the head through the cervical chain ganglia.
Viscerosomatic Reflex
Palpatory and other TART changes in the upper thoracic and cervical
paraspinal tissues indicate increased functional activity of the sympathetic
nervous system
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Superior sympathetic ganglion - Close proximity to OA & AA
Middle sympathetic ganglion
Inferior sympathetic ganlion
Chapmans reflexes are another sign of viscerosomatic reflexes.
Increased Sympathetic Tone
Vasoconstriction of vessels
Diminishes nutrient supply to the tissues (including medications)
Reduces lymphaticovenous drainage
Increased number of goblet cells
Leads to thick and sticky respiratory epithelium = decreased mobility
of the mucous
Inhibits secretion
Dryness and cracking of the mucosa can lead to secondary bacterial
infections
Goblet cells are increased with chronic irritation.
Decreased vascular elements also has an effect.
Stimulation of nasopharyngeal mucous membranes
Pseudoephedrine - Contribute to the sympathetic response. They are
alpha1 - agonists. Cause vasoconstriction. Rebound congestion is a
problem with this drug. Sympathomimetic.
TO SUM UP….Increased sympathetic tone leads to a lowered ability of the body’s
immune system to mount an effective response
This includes the bodies ability to get adequate medication concentrations to the areas
that need it.
Parasympathetic Innervation
Postganglionic fibers from the sphenopalatine ganglion
AKA pterygopalatine ganglion
Via CN VII
Secretomotor supply to the nasal glands
Innervation of lacrimal gland
Parasympathetic Hyperactivity
Profuse, clear, thin secretions from the mucosa of the nasopharynx and
sinuses
Sphenopalatine syndrome (with prolonged stimulation –Hyperparasymp)
“described as redness and engorgement of the mucous membranes,
photophobia, tearing and pain behind the eyeball, nose, neck, ear, or
temple.”
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This may complicate asthma due to the inability of the nasal mucosa to
resist foreign proteins and adequately condition the air.
Sphenopalatine Ganglia ---Key to the parasympathetics
What are you treating?
Parasympathetics
Goal of Treatment?
Thin the mucous secretions so the sinuses can drain.
You will need some gloves
Sphenopalatine Ganglion
(aka Pterygopalatine ganglion) ---btwn. Sphenoid, maxillary, and pallatine bones
Notice - Maxilla and pterygoid plate of the sphenoid
Sphenonpalatine Ganglion Technique
Slide your gloved pinky external to the teeth (but yes, inside the mouth)
Continue until your finger passes between the teeth and the mandible. There should
be a small depression after the last molar.
Add passive pressure over the lateral pterygoid muscle - have the patient lean his or
her head towards your finger.
Do not jam your finger into the pterygoid - it will break!
Continue this until you notice unilateral tearing ---sign of PSNS stimulation
OA Dysfunction
Why treat the OA?
Trace the course of CN VII
Relation to the temporal bone
What “drives” the temporal bone?
That’s right, the occiput!
85% of venous drainage of the head is through the Jugular veins
Pass through the jugular foramen
Superior sympathetic ganglion
Vagus is not parasympathertic innervation in this case. Although the Vagus would be
important in the treatment of OM
OA Extension SD
Instruct patient to forward bend, allowing you to contact the arch of the atlas just
inferior to the occiput in the midline.
Once you find the atlas, instruct the patient to tuck his or her chin. With your anterior
hand, add a slight posterior and caudal pressure to the forehead (same direction as
patient’s force of the tuck).
Instruct patient to breath deeply.
Maintain contact until there is motion at the OA
Not ME, direct myofascial release of fascial tension and muscles
For Sidebending SD, think of backing up of occiput out of atlas
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Galbreath Technique
What are we affecting?
Mandibular drainage
Why is this important?
Drainage of nasopharyngeal area
Decongestion
Opening of pharyngotympanic (eustachian) tube
Normalizes pressure and improves drainage
OM and sinusitis often have a bronchial process going on as well.
Major cause of OM is eustachian tube dysfunction
Tissue swelling and edema
Adhesions post surgery or infection
Trigger points in the medial pterygoid
The efficiency of this treatment is accounted for by the alternate ‘make and break’
tension placed on the pterygoid muscles (esp the medial pterygoid) in and on which
is located the rich pterygoid venous plexus which drains the region under
consideration. The value of this treatment in the treatment of tubal catarrah,
tubotympanic catarrah, and otitis media as well as in promoting drainage of the
air sinuses should be appreciated.”
Angus Cathie, AAO Yearbook 1974, page 181
Catarrah - Inflammation of the mucous membrane with increased flow of mucous or
exudate (Stedman’s)
Medial & Lateral Pterygoid Muscles (Netter 49)
Here are the pterygoid muscles and the venous plexus overlying it.
Galbreath Technique
Patient supine with head elevated and rotated 90o to the side opposite the side to be
treated (rotate right to tx the left)
Operator stands on side pt is facing, placing the fingers of the caudal hand below the
zygomatic arch and over the temperomandibular joint.
The heel of the same hand contacts along the mandible to the chin (symphysis menti)
Patient must relax the lower jaw. Doctor uses a inferior, anterior, and medial force
with the caudal hand. Release and repeat slowly and firmly.
Cephalad hand is placed on the patient’s frontoparietal region to steady the patient’s
head
Important that they open mouth a little to relax the jaw
Lymphatics
Lymph congestion
Boggy edematous tissue
Decrease transport of nutrients to the tissue
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Decreased removal of metabolic wastes from mucosa
Hinders homeostatic mechanisms
GOAL - Open lymphatic pathways while avoiding direct manipulation of swollen
lymph nodes
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Parotid Lymph nodes - Drain the anterior wall of the external auditory meatus
Submandibular nodes - Drain the nose, frontal, maxillary, and ethmoid sinuses
Retropharyngeal nodes - Drain the nasal part of the pharynx, and auditory tube
The Deep Cervical Lymph nodes - Drain all of the above.
Jugulodigastric node - drains the tonsils (Important)
Effleurage of the Lymphatics
Important to treat in the order presented because of direction of flow
Free Sibson’s Fascia
1. Frontal
2. Supraorbital
3. Infraorbital
4. Submandibular
Lightly dragging fingers. Remember what Aaron said with the Lower extremity this
is like milking the tissue.
Current Research
“The Use of Osteopathic Manipulative Treatment as Adjuvant Therapy in Children
with Recurrent Otitis Media.”
Archives of Pediatric and Adolescent Medicine. Vol 157(9), September 2003, pp
861-866
Miriam Mills MD; Charles Henley DO; Laura Barnes PhD; Jane Carriero DO;
Brian Degenhardt DO
2 groups
Routine pediatric care (32)
Routine pediatric care + OMT (25)
Outcome measures
Frequency of episodes of AOM
Antibiotic use
Surgical interventions
Tympanometric and audiometric performance
Behaviors
Results
Intervention patients had
Less episodes AOM
Fewer surgical procedures
More surgery free months
Increase frequency of normal tympanograms
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