Presentation on theme: "American College of Osteopathic Pediatricians Kate Ruda Wessell, DO"— Presentation transcript:
1 Osteopathic Manipulation for Acute Otitis Media in the Pediatric Population American College of Osteopathic PediatriciansKate Ruda Wessell, DOPediatric ResidentRainbow Babies and Children’s HospitalPGY-1January 23, 2011
4 Ear AnatomyOuter Ear: Pinna, External Auditory Meatus, Outside of Tympanic MembraneMiddle Ear: Inside of Tympanic Membrane, 3 ossicles; Malleus, incus, and stapes and Eustachian TubeInner 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 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 catarrhalisSigns/Symptoms-discomfort, “popping”, pressureDiagnosis:-visualization of the TM, tympanic insufflator
6 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
7 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 adulthood60-80% of infants have at least 1 episode of AOM by age 1 year80-90% by age 2 to 3 years
8 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
9 Otitis Media Treatments Observation and Self-Limitation: based on diagnostic certainty, age, illness severity, and assurance of follow- upPain Remedies: topical agents (Auralgan), oral agentsAntihistamines, decongestants, steroidsAntibioticsOMTTympanostomy Tubes
10 Treatment: Antibiotics Amoxicillin mg/kg/day divided BID for 5-7 days for episodes in most children 6 yrs of age or olderYounger 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 coursePersistent middle ear effusion for 2-3 months after therapy for AOM is expected and does not require routine retreatmentIf effusion lasts greater than 3 months, tx for days may be consideredAmerican 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, 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 effectivelyAuricular Drainage Technique
12 Specifics of the Galbreath Maneuver The 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.
14 Auricular Drainage Technique This 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.
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 effusionReduces recurrence rates in the 6 months after placement
17 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
18 Evidenced Based Medicine Study 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.
19 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
20 Hands On: Time to Practice LandmarksSympathetic InnervationOrder of Treatment to maximize technique efficacy:-Stretching-Myofascial Release of Restrictions/Choke Points-Galbreath Technique-Auricular Drainage-Lymphatic Pump
21 1.2.LANDMARKSLocate the Ear of Your PatientImagine the Inner Ear AnatomyImagine the Lymphatic System Surrounding the Ear Anatomy3.
22 Innervation Table EENT Organ/System Parasympathetic Sympathetic Ant. Chapman'sPost. Chapman'sEENTCr Nerves (III, VII, IX, X)T1-T4T1-4, 2nd ICSSuboccipitalHeartVagus (CN X)T1-4 on L, T2-3T3 sp processRespiratoryT2-T73rd & 4th ICST3-5 sp processEsophagusT2-T8---ForegutT5-T9 (Greater Splanchnic)Stomach5th-6th ICS on LT6-7 on LLiverRib 5 on RT5-6GallbladderRib 6 on RT6SpleenRib 7 on LT7PancreasT5-T9 (Greater Splanchnic), T9-T12 (Lesser Splanchnic)Rib 7 on RMidgutThoracic Splanchnics (Lesser)Small IntestineT9-T11 (Lesser Splanchnic)Ribs 9-11T8-10Appendix T12Tip of 12th RibT11-12 on RHindgutPelvic Splanchnics (S2-4)Lumbar (Least) SplanchnicsAscending Colon Vagus (CN X)T9-T11 (Lesser Splanchnic)R hipT10-11Transverse ColonNear KneesDescending ColonPelvic Splanchnic (S2-4)Least SplanchnicL hipT12-L2Colon & RectumPelvic Splanchnics (S2-4)T8-L2
28 Question 1: What is the most common bacterial cause of AOM? Haemophilus InfluenzaStreptococcus pneumoniaMoraxella catarrhalisPseudomonas aeruginosa
29 Question 2:What is the most sensitive diagnostic tool for diagnosing AOM?Visualization of TM with otoscopePneumatic otoscopyA child tugging at their earsFever 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 PumpB. Auricular Drainage, Galbreath Technique, Stretching, Restriction ReductionC. Stretching, Restriction Reduction, Galbreath Technique, Auricular Drainage, Lymphatic PumpD. Lymphatic Pump, Galbreath Technique, Auricular Drainage, Stretching, Restriction Reduction
31 Summary Ear Anatomy Otitis Media: causes, diagnosis, treatment OMT 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
32 SPECIAL THANKS TO MY PATIENTS: HAYDEN AND MAYCEE
33 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 Oct; 45 (10):JAOA Vol 100. No 10. October “Galbreath Technique: a manipulative treatment for Otitis Media Revisited” pgsJAOA Vol 106 No 06 June “Osteopathic Evaluation and Manipulative Treatment in Reducing the Morbidity of Otitis Media: A pilot study.” Degenhardt, Kuchera pgsRed 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.)