An Integrated Osteopathic Treatment Approach in Acute Otitis Media
Total Page：16
File Type：pdf, Size：1020Kb
C A RF IC)RT S • An integrated osteopathic treatment approach in acute otitis media WILLIAM J. PINTAL, no MARGOT E. KURTZ, PhD Ear pain is a common patient pathogens, Streptococcus pneumoniae and Haemo- complaint in the practice of the primary philus influenzae, causative agents may include care physician. Acute otitis media can Streptococcus pyogenes, Staphylococcus aureus, My- affect a person of any age, although it is coplasma pneumoniae, and Corynebacterium diphth- more often seen in children than in adults. eriae. The disease is usually caused by Classically, the tympanic membrane is thick- Streptococcus pneumoniae (Diplococcus ened, and a gray or amber fluid is seen in the mid- pneumoniae) or Haemophilus influenzae. dle ear. Sometimes a fluid meniscus, air bubbles The differential diagnosis and subsequent of bluish fluid, may appear behind the tympanic treatment of otitis media is approximately membrane, the mobility of which is generally im- the same for children and adults. First-line paired. Depending on individual circumstances, the therapy usually consists of an antibiotic tympanic membrane may be either bulging or re- regimen of amoxicillin in combination with tracted. The bulging or retraction may result from autoinflation exercises. In the case the development of a positive or negative internal presented, a pharmacologic regimen was pressure, respectively, caused by dysfunction of the combined with osteopathic manipulation. eustachian tube. In the differential diagnosis, one must distin- guish between an acute purulent otitis media and In the course of caring for a wide range of pa- a serous or mucoid otitis media as well as between tients of different ages in a general practice–fam- the short-term perforation of the tympanic mem- ily medicine setting, one has the opportunity to care brane that is associated with acute purulent otitis for many ear infections. While managing these media and the long-term perforation causing cases, we became aware that an integration of os- chronic drainage that is associated with chronic teopathic management offered a faster, more per- suppurative otitis media. The possibility of suppu- manent recovery than just the routine kind of care. rative otitis externa should be considered. Gener- This case report epitomizes one philosophy of di- ally, an acute bacterial effusion in the ear calls agnosis, treatment, and management of acute oti- for the use of antibiotics. When the causative agent tis media. has not been identified, amoxicillin is recom- In adults, acute purulent/suppurative otitis me- mended as the initial therapy. If amoxicillin proves dia includes the development of middle ear effu- ineffective, cefaclor (Ceclor) is often beneficial. In sion, associated with eustachian tube dysfunction addition, autoinflation exercises, which involve blow- and retrotympanic pressure changes. Often this ef- ing the nose with a gently controlled force while fusion accompanies another condition such as an the mouth and nose are kept closed, are also upper respiratory tract infection, chronic rhino- thought to complement treatment." sinusitis of bacterial or allergic origin, nasopharyn- geal tumor, nasal polyps, or dysfunction of the soft Report of case palate. In most cases in which the effusion persists, A 45-year-old woman came to a family medicine clinic bacteria are present. In addition to the primary because she had recurring severe pain in both ears, with Case Report • Pintal and Kurtz JAOA - Vol 89 • No 9 • September 1989 • 1139 some hearing loss, and a roaring sound in the right ear. osteopathic techniques was used. The pharmacologic regi- The night before she was seen, the patient had had se- men included cefaclor (500 mg orally for 3 days, then vere pain in both ears, both externally and internally; 500 mg orally for 5 days, followed by 250 mg orally for some dizziness; fever; and sweats. Describing the pain 6 days). Second, to facilitate healing, several specifically as a severe pressure, she expressed the concern that her planned manipulative methods were used: "eardrums might burst." • deep, penetrating soft tissue releases at both mandi- A thorough history revealed chronic ear infections as bular angles to increase blood supply and facilitate a child but no instance of trauma to the head or disease drainage around the eustachian tubes; of the nose, nasopharynx, paranasal sinuses, mouth, hy- • hyoid release obtained by using direct articulatory ap- popharynx, larynx, or neck. The most recent episode of proach, with subsequent alternating pressure to the ear infection had occurred 4 weeks previously and had lateral anterior aspect of the neck to stimulate eusta- responded minimally to antibiotics. In all other aspects, chian tube drainage along with generalized lymphatic the patient reported being in excellent health except for and venous drainage; having a severe hypersensitivity to local anesthetics, • bilateral shoulder raising to act as a lymphatic pump; sulfa, ragweed, and seafood. • traditional osteopathic manipulative treatment, in Physical examination showed a well-nourished, well- which a direct muscle energy approach to the cervical hydrated woman experiencing acute bilateral ear pain. spine was used, specifically at the level of C-1 and C-2; Her oral temperature was 99.5°F; blood pressure, 123/ • myofacial release technique to soft tissues, deep to the 68 mm Hg; respirations, 16 per minute; and pulse rate, angles of the mandible; 68 beats per minute. Examination of the right ear • generalized anterior cervical soft tissue technique to showed an erythematous external ear that was sensi- facilitate arterial, venous, and lymphatic circulation tive to the touch. The external auditory canal was pat- in and about the head and neck; and ent, with no cerumen and minimal erythema, but sensi- • cranial technique with specific emphasis on balanc- tive to the introduction of the speculum. The tympanic ing. membrane was red and bulging and showed evidence The regimen was used for 5 days. lb complement of residual scarring. The membrane appeared thickened, manipulative treatment, the patient was taught to self- and the middle ear was filled with fluid. No evidence administer anterior cervical soft tissue and hyoid bone of perforation, meniscus, or air bubbles was observed. movements. She was also taught Valsalva autoinfla- Examination of the left ear showed minimal erythema tion exercises designed to stimulate movement of the of the auditory canal. Again, the tympanic membrane tympanic membranes, mobilize the effusions, and main- was erythematous and bulging, although somewhat less tain patency of the eustachian tubes. so than in the right ear. Middle ear congestion was also Patient education emphasized proper rest and well- evident. The nasal examination showed no abnormali- balanced nutrition, including adequate hydration to ties. There were mild to moderate hyperemic mucous encourage thinning of body secretions. tracks in the posterior aspect of the pharynx. There was Within 24 hours, the patients temperature returned mild lymphadenopathy in the right anterior cervical lym- to normal and the erythema decreased bilaterally. phatic chain, and the lungs were clear bilaterally. Tis- Drainage from the eustachian tubes occurred; the pa- sue texture was abnormal at the mandibular angles bi- tient reported having a foul-tasting material in the laterally. There was a generalized decrease in cervical throat when the areas around the eustachian tubes mobility, particularly at the first and second cervical were manipulated. By day 4, pain and ear pressure segments. had disappeared. The patient reported hearing pop- The initial differential diagnosis included acute pu- ping sounds over several days; and as her eustachian rulent otitis media, acute serous otitis media, mucoid tubes cleared, her hearing gradually improved. She otitis media, acute suppurative otitis media, chronic sup- noticed a feeling of general well-being. After day 14, purative otitis media with exacerbation, cholesteatoma, antibiotics were no longer needed. The ears were com- and nasopharyngeal tumor. The patient was referred to pletely clear with the exception of residual tympanic an otolaryngologist for immediate consultation and audi- scarring. The patient has continued autoinflation ex- ology testing. The x-ray findings were normal; the bilat- ercises as a prophylactic measure. At 9-months eral hearing loss was mild to moderate for high frequency posttreatment, she has been free of recurrence. sounds; and the diagnosis of acute purulent otitis media was confirmed. The otolaryngologist scheduled the pa- Summary tient for myringotomy, drainage, exploration, and place- Acute purulent otitis media is frequently seen in ment of tubes to be performed 8 days later. Because of her hypersensitivity to local anesthetics and her con- children and adults. The disease may involve in- cerns regarding the surgery, the patient returned to the flammation of the tympanic membrane, dysfunc- clinic to discuss her case. She requested rigorous conser- tion of the eustachian tube, changes in or devia- vative treatment in an attempt to avoid surgery. tion from normal pressure of the middle ear, and A rigorous course of treatment with antibiotics and accumulations of purulent material behind the tym- 1140 • JAOA • Vol 89 • No 9 • September 1989 Case Report • Pintal and Kurtz panic membrane. In the case we report here, the patient responded well to a treatment regimen that combined antibiotic therapy and manipulative pro- cedures. Although