Presentation on theme: "Osteopathic Treatment For Patients With Sinusitis"— Presentation transcript:
1 Osteopathic Treatment For Patients With Sinusitis
2 3D frontal viewJello 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 daysUnable to clear secretions when blowing nosePost nasal drip with minimally productive coughGets 2-3 sinus infections/year
4 PM/Surg/Soc/FamHX: Occipital/Tension headaches GERD, usually controlled but symptomatic when has post nasal dripIrregular menses/perimenopausalEnvironmental allergies trigger sinusitis in spring and fallsinus surgery 2 yrs ago helped, but didn’t resolve problemsNonsmoker, no petsSeveral siblings with chronic sinus problems
5 Trauma/Birth HistoryOnset 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 symptomsNKDA
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 LPharynx injected, pebbled, without exudate or tonsillar enlargementYellow post-nasal drip
8 Physical Exam Tender to palpation frontal, nasal and left maxilla No cervical, supraclavicular or infraclavicular adenopathyLungs CTABHeart RRR without murmurMinimal epigastric tenderness, no mass/rebound tenderness/rigidity/guarding
9 Structural Exam Thoracic inlet sidebent right, rotated left Structural ExamThoracic inlet sidebent right, rotated leftFirst rib superior on the leftPositive Left anterior subclavicular Chapman’s reflexesBilateral posterior upper cervical Chapman’s reflexesC2 FRSROA FSLRRThese 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.
12 More Structural Exam Decreased CRI Poor compliance/tender at left mastoid process and nasionLeft maxilla internally rotatedLeft 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/PlanAcute 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 patientIndirect or direct MFR to thoracic inlet and thoracoabdominal diaphragm if neededME, FPR or BLT to left first ribTreat 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 StillSacral 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 ganglionMiddle cervical ganglionInferior cervical ganglion
17 Where would you start for this set of cranial findings? Where would you start for this set of cranial findings?Decreased CRIPoor compliance/tender at left mastoid process and nasionLeft maxilla internally rotatedLeft 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 liftAlternating lateral rocking of the nasionSphenopalatine ganglion releasePercusssion/ “jello tap” over involved sinusesEffleurage over frontals, nasals, maxillae and towards mastoidsSupra & Infra orbital nerve stimulationChampions 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 ReleaseCephalad Hand contacts the frontal with two finger padsCaudad Hand contacts the two nasal bones with thumb and indexGently distractCan also be done for fronto-maxillary sutures.
21 Supraorbital and Infraorbital Foramina Locate the foramen along the superior orbital ridge or the inferior orbitGentle finger pad contact is used to massage the nerve and surrounding tissuesA 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 GanglionIntimate relationship with the Maxillary Branch of the Trigeminal N.Note Relative flatness of pterygoid process compared to rounded maxillaSutherland, Teachings in the Science of Osteopathy, p. 96
24 Sphenopalatine Ganglion Note that the spenopalatine ganglion is suspended from the maxillary nerveSutherland, Teachings in the Science of Osteopathy, p. 96
25 Treatment of the Sphenopalatine Ganglion Stand opposite the side to be treatedCaudal 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 maxillaThe patient may have to move the ramus of the jaw laterally to create room for the fingerCraniosacrale 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, orapply gentle inhibitory pressure medially & cranially in the direction of the outer orbitIt can be quite painfulPressure on the ganglion will stimulate it to action which will be indicated by lacrimationDecreased tissue tension also indicates completion of this techniqueCraniosacrale 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 diameterGentle pressure is directed toward the ganglion in coordination with the cranial impulseUnwinding Technique:Cranial Hand contact on the greater wings to monitor motionRelease will follow from a forceful flexion motion that can be felt By the cranial handCraniosacrale Osteopathie II, p.99
29 FacilitatorsDo not try to go through the venous sinus drainage technique during the presentation. It takes too longStudents can be given a handout of it to take home for practice.