Osteopathic Manipulation for Acute
Otitis Media in the Pediatric
Population
American College of
Osteopathic
Pediatricians
Kate Ruda Wessell, DO
Pediatric Resident
Rainbow Babies and Children’s
Hospital
PGY-1
January 23, 2011
Ear Anatomy
Normal TM
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
Otitis Media
 Inflammation of the Middle Ear
 Location between the tympanic membrane and the inner ear


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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
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
Kids > 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
Risk Factors for AOM
 Opportunity for Patient Education for the General
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


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
Otitis Media Treatments
 Observation and Self-Limitation: based on diagnostic

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certainty, age, illness severity, and assurance of followup
Pain Remedies: topical agents (Auralgan), oral agents
Antihistamines, decongestants, steroids
Antibiotics
OMT
Tympanostomy Tubes
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
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
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 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 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
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 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
Evidenced Based Medicine
 Case 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 Medicine
 Study Design:Pilot cohort study with 1 year posttreatment follow
up
 Subjects: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 Medicine
 Conclusion: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 Practice
 Landmarks
 Sympathetic Innervation
 Order of Treatment to maximize technique efficacy:
-Stretching
-Myofascial Release of Restrictions/Choke Points
-Galbreath Technique
-Auricular Drainage
-Lymphatic Pump
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.
Organ/System
Parasympathetic
Sympathetic
Ant.
Chapman's
Post.
Chapman's
T1-T4
T1-4, 2nd ICS
Suboccipital
Heart
Cr Nerves (III, VII, IX,
X)
Vagus (CN X)
T1-T4
T3 sp process
Respiratory
Vagus (CN X)
T2-T7
T1-4 on L,
T2-3
3rd & 4th ICS
Esophagus
Vagus (CN X)
T2-T8
---
T3-5 sp
process
---
Foregut
Vagus (CN X)
T5-T9 (Greater Splanchnic)
---
---
Stomach
Vagus (CN X)
T5-T9 (Greater Splanchnic)
Liver
Vagus (CN X)
Gallbladder
EENT
T6-7 on L
T5-T9 (Greater Splanchnic)
5th-6th ICS on
L
Rib 5 on R
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)
Rib 7 on R
T7
Midgut
Vagus (CN X)
T5-T9 (Greater Splanchnic), T9T12 (Lesser Splanchnic)
Thoracic Splanchnics (Lesser)
Small Intestine
Vagus (CN X)
T9-T11 (Lesser Splanchnic)
Ribs 9-11
T8-10
Tip of 12th Rib
T11-12 on R
Appendix
Hindgut
Ascending Colon
Transverse Colon
T12
Pelvic Splanchnics (S24)
Vagus (CN X)
Vagus (CN X)
Lumbar (Least) Splanchnics
T9-T11 (Lesser Splanchnic)
T5-6
---
---
---
--T10-11
T9-T11 (Lesser Splanchnic)
R Femur @
hip
Near Knees
L Femur @ hip
T12-L2
Descending Colon
Pelvic Splanchnic (S2-4)
Least Splanchnic
Colon & Rectum
Pelvic Splanchnics (S24)
T8-L2
---
---
---
STRETCHING
MYOFASCIAL RELEASE
GALBREATH TECHNIQUE
AURICULAR DRAINAGE
LYMPHATIC PUMP
Question 1:

What is the most common bacterial cause of AOM?
A. Haemophilus Influenza
B. Streptococcus pneumonia
C. Moraxella catarrhalis
D. Pseudomonas aeruginosa
Question 2:

What is the most sensitive diagnostic tool for
diagnosing AOM?
A. Visualization of TM with otoscope
B. Pneumatic otoscopy
C. A child tugging at their ears
D. 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
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
SPECIAL THANKS TO MY PATIENTS: HAYDEN AND MAYCEE
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 327334
Red Book: 2009 Report of the Committee on Infectious Disease. American Academy of
Pediatrics “Otitis Media” page 741.
UpToDate: Acute Otitis Media in Children
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completed the Pediatric OMT Module on __ __ 20__
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 Pediatric Residency Director____________
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