1. Osteopathic Treatment For Patients With Sinusitis

2. 3D frontal view
Jello tap over frontal, maxillary sinuses. Note entry of tooth roots into maxillary sinuses.

3. 47 Year old female with frontal headache and yellow nasal discharge
Fronto-occipital headache, face pain and sore throat x 4 days
Unable to clear secretions when blowing nose
Post nasal drip with minimally productive cough
Gets 2-3 sinus infections/year

4. PM/Surg/Soc/FamHX: Occipital/Tension headaches
GERD, usually controlled but symptomatic when has post nasal drip
Irregular menses/perimenopausal
Environmental allergies trigger sinusitis in spring and fall
sinus surgery 2 yrs ago helped, but didn’t resolve problems
Nonsmoker, no pets
Several siblings with chronic sinus problems

5. Trauma/Birth History
Onset occipital headaches when stood up into a 4x6 board 12 years ago, hitting on the back of the head. Lost consciousness for a few minutes.
Was a “large baby”, otherwise unknown

6. Meds/Allergies Omeprazole, Loratidine, Multivitamin, Calcium +D.
Azithromycin, Guaifenesin, nasal steroids are the usual sinusitis regimen that resolves her symptoms
NKDA

7. Physical Exam VSS Afebrile NAD HEENT: NC/AT, face symmetrical
TM grey with good landmarks but left retracted. No effusion.
Nasal mucosa swollen with yellow drainage from ostia L
Pharynx injected, pebbled, without exudate or tonsillar enlargement
Yellow post-nasal drip

8. Physical Exam Tender to palpation frontal, nasal and left maxilla
No cervical, supraclavicular or infraclavicular adenopathy
Lungs CTAB
Heart RRR without murmur
Minimal epigastric tenderness, no mass/rebound tenderness/rigidity/guarding

9. Structural Exam Thoracic inlet sidebent right, rotated left
Structural Exam
Thoracic inlet sidebent right, rotated left
First rib superior on the left
Positive Left anterior subclavicular Chapman’s reflexes
Bilateral posterior upper cervical Chapman’s reflexes
C2 FRSR
OA FSLRR
These are deliberately arranged in the order that they respond well to treatment. The order of the techniques in the lab should match, to facilitate good habits later.

10. Anterior Chapman’s Reflex

11. Posterior Chapman’s Reflex

12. More Structural Exam Decreased CRI
Poor compliance/tender at left mastoid process and nasion
Left maxilla internally rotated
Left pterygopalatine fossa soft tissues boggy

13. What else should be included?
Structural exam: thoracoabdominal diaphragm. Mention of negative (or positive) reflexes for pyloris/stomach. Findings of head CT: chronic pansinusitis but otherwise normal. No immunodeficiency on lab workup. May be other antibiotic choices.

14. Impression/Plan
Acute on chronic sinusitis. Allergic rhinitis. Left eustachian tube dysfunction. Gerd. Somatic dysfunction head, neck, ribs, thorax.
Discuss pharmacologic treatment, hydration, reduction of exposure to allergens briefly and move on to lab section.

15. Possible treatment sequence for this patient
Possible treatment sequence for this patient
Indirect or direct MFR to thoracic inlet and thoracoabdominal diaphragm if needed
ME, FPR or BLT to left first rib
Treat posterior cervical Chapman’s reflexes.
Check to see if anterior reflexes less tender. If not, treat them too.
Treat upper cervicals with suboccipital release, ME, BLT or Still
Sacral motion restriction may need to be addressed.
These are not the focus of the lab, but need to be mentioned

16. Sympathetic Relationships in the Cervical Region:
Superior cervical ganglion
Middle cervical ganglion
Inferior cervical ganglion

17. Where would you start for this set of cranial findings?
Where would you start for this set of cranial findings?
Decreased CRI
Poor compliance/tender at left mastoid process and nasion
Left maxilla internally rotated
Left pterygopalatine fossa soft tissues boggy

18. Possible sinusitis techniques
Choose which apply to your site then delete the irrelevant slide(s)
Venous sinus drainage sequence (precede with OA release and end with frontal/parietal lifts)
Fronto-zygomatic lift
Alternating lateral rocking of the nasion
Sphenopalatine ganglion release
Percusssion/ “jello tap” over involved sinuses
Effleurage over frontals, nasals, maxillae and towards mastoids
Supra & Infra orbital nerve stimulation
Champions may want to choose several of these techniques upon which to focus.

19. Nasion, Supraorbital and Infraorbital Foramina
Frontal Lift. Nasion spread. Supraorbital and Infraorbital nerve counterirritation.

20. Fronto-nasal Release
Cephalad Hand contacts the frontal with two finger pads
Caudad Hand contacts the two nasal bones with thumb and index
Gently distract
Can also be done for fronto-maxillary sutures.

21. Supraorbital and Infraorbital Foramina
Locate the foramen along the superior orbital ridge or the inferior orbit
Gentle finger pad contact is used to massage the nerve and surrounding tissues
A slow rotary motion back and forth is often quite effective.
This can be easily taught to the patient for home use.

22. Trigeminal Nerve, Sphenopalatine Ganglion
Extension from trigeminal to supraorbital and infraorbital nerves. Intraoral SPG release.

23. Intimate relationship with the Maxillary Branch of the Trigeminal N.
Sphenopalatine Ganglion
Intimate relationship with the Maxillary Branch of the Trigeminal N.
Note Relative flatness of pterygoid process compared to rounded maxilla
Sutherland, Teachings in the Science of Osteopathy, p. 96

24. Sphenopalatine Ganglion
Note that the spenopalatine ganglion is suspended from the maxillary nerve
Sutherland, Teachings in the Science of Osteopathy, p. 96

25. Treatment of the Sphenopalatine Ganglion
Stand opposite the side to be treated
Caudal Hand: Introduce the little finger of the caudal hand softly & carefully along the alveolar ridge past the tuberosity of the maxilla on to the lateral plate of the pterygoid – it is a flatness in contrast to the curved maxilla
The patient may have to move the ramus of the jaw laterally to create room for the finger
Craniosacrale Osteopathie II, p.99

26. Treatment of the Sphenopalatine Ganglion
Once in position have the patient tip the head against the pad of the little finger to tolerance, or
apply gentle inhibitory pressure medially & cranially in the direction of the outer orbit
It can be quite painful
Pressure on the ganglion will stimulate it to action which will be indicated by lacrimation
Decreased tissue tension also indicates completion of this technique
Craniosacrale Osteopathie II, p.99

27. References Grant’s Atlas Digital Images
American Academy of Otolaryngology - Head and Neck Surgery  One Prince Street Alexandria, VA

28. Treatment of the Sphenopalatine Ganglion
Fluid-wave Technique:
Cranial Hand’s Thumb is on the coronal suture opposite the sphenopalatine ganglion contact – at the longest diameter
Gentle pressure is directed toward the ganglion in coordination with the cranial impulse
Unwinding Technique:
Cranial Hand contact on the greater wings to monitor motion
Release will follow from a forceful flexion motion that can be felt By the cranial hand
Craniosacrale Osteopathie II, p.99

29. Facilitators
Do not try to go through the venous sinus drainage technique during the presentation. It takes too long
Students can be given a handout of it to take home for practice.