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Home , Deep temporal nerves, Mastoid cells, Sphenoid bone, Temporal bone

The temporal : Trouble maker in the head

HAROLD I. MAGOUN, SR., D.O., FAAO Belen, New Mexico

function, produce tension in nerves or fascia, and generally upset homeostasis in this area. Physicians knowledgeable about osteopathic Likewise, many of the problems in the area of theory and procedures in the cranial field the eye, , nose, and throat have roots in have found it possible to relieve many structural abnormalities that affect the tem- conditions that result from abnormalities poral bone. Temporal bone syndromes, how- in the position and motion of temporal . ever, go far beyond these areas of practice. Structural deviations of these bones may be This may seem to be a questionable concept responsible for migraine headaches, vertigo, to physicians who were led to believe that the strabismus, and malocclusion of the teeth, is a solid ivory tower. This misconception as well as bruxism and nystagmus. has arisen because textbook writers started Correction of these deviations is not a with a false premise. Their descriptions were cure-all, but often long-standing conditions written from study of dry, defatted laboratory erroneously attributed to other causes may specimens, not of living, resilient bone. To be relieved by manipulative measures. It contemplate flexibility in a structure that does not require a great deal of training to through the ages has been considered im- perceive movement or to detect slight mobile calls for flexibility in the thinking distortions or lack of motion. process.

Basic anatomy Before the position and/or motion of the tem- poral bone are considered in relation to the disorders possibly connected with abnormal- Pursuant to his observation that the spheno- ities thereof, it would be well to review the squamous suture is "beveled like the gills of a general anatomy and the physiologic move- fish and indicating articular mobility," Suther- ment involved. land delved into the intricacies of the anatomy Each temporal bone makes up the middle of and physiology of the temporal bone, one side and the base of the skull, filling in be- especially at the sutural bevel, as few others tween the with its sphere of in- ever have done. His studies led him into a fluence anteriorly and the occiput and its therapeutic complex involving a field so vast sphere of influence posteriorly. The fact that that he was led to call the temporal bone "the the articulates with the temporal trouble maker in the head." Trouble maker or bones tends to complicate these relations. victim of circumstances, this structure is in- Each temporal bone consists of three parts. volved in a wide range of pathologic condi- The scalelike squama carries the external tions. Consequently, a knowledge of its rela- ear and the . The breastlike tionships is of great importance to any mastoid process contains the and physician or dentist. the antrum, but the mastoid is not fully de- From the dental point of view, perversion of veloped until near the end of the first year of physiologic motion or traumatic fixations in- life. The petrous portion, named for its rock- evitably will disturb temporomandibular and like consistency, houses the important organs occlusal harmony, alter muscle position and of and equilibrium, forms the medial

Journal AOA/vol. 78, June 1974 825/89 Temporal bone

wall of the cavity, and carries the It should be noted further that the pet- exit of the bony part of the . rosphenoid articulation also is cartilaginous Shaped like a pyramid, it contains many im- throughout life—a sign that it is designed for portant structures. Its posterior surface is motion—and that the petrous ridge, just back pierced by the opening of the internal acoustic of its anterior tip, is notched to allow for the meatus for the seventh and eighth cranial crossing of the root of the fifth cranial nerve. nerves, as well as the for Also in this immediate area the forward the ductus endolymphaticus. The anterior sur- reaches of the tentorium cerebelli, known as face is hollowed at its mesial end to accommo- the petrosphenoid ligaments, insert into the date the and contains also posterior clinoid processes of the sphenoid the hiatus fallopii of the greater superficial bone overlying the sixth cranial nerve on petrosal nerve. Inferiorly there are attach- either side. ments for muscles, the pharyngeal aponeuro- In order to understand the possible patho- sis, the opening of the , the jugu- logic influences of the temporal bone, one must lar surface for articulation with the jugular visualize the basic anatomic relations just de- process of the (cartilaginous scribed. To appreciate its physiologic motion, throughout life), and the styloid foramen for one must be familiar with the sutural bevels the seventh cranial nerve. All these are im- around its entire periphery (Fig. 1). An over- portant in one type of pathologic change or simplified description of these sutural con- another that is related to abnormal position formations might state that the upper half of or unphysiologic motion. the bone is beveled internally, at the expense

Fig. 1. Interior view of the left temporal bone.

826/90 of the inner table of bone, where it articulates veloped abnormally can be most significant. A with the parietal and sphenoid bones. At the blow on the is transmitted directly to the sphenosquamous and the condylosquamomast- skull by way of the temporomandibular artic- oid pivots, the bevel becomes external in its ulation. But the temporal bone suffers the lower half, at the expense of the outer table most. Trauma to the vault or base, to the fron- of bone. The structure might be compared tal bone or occiput, can hardly escape disturb- roughly to that of a casement window swing- ing the temporal bone because of the added ing externally above and internally below its complication of its position between the horizontal axis. spheres of influence of the sphenoid bone and Noting this conformation, Sutherland 2 the- occiput. It has to absorb or compensate for orized that a temporal bone could be disarticu- diverse influences from both ends. lated from an intact skull with the proper lev- The lifelong pattern of position of the tem- erages. The head of the anatomy department poral bone and consequently of the ear is de- of one of the osteopathic colleges insisted that termined perinatally. Without giving the mat- this was preposterous, that this could not be ter a thought one is inclined to overlook the done with a crowbar. In this he was correct, varying positions of the of ones daily but Sutherland succeeded in removing just the companions, whether they are close to the undamaged temporal bone with a penknife. head, divergent, or a combination of these. This spurred him to further study. His conclu- Indeed, anatomists who judge from dry, dead sions have been supported by continuing clini- laboratory material have concluded that the cal experience. idea of "bone rotation as a cause of protrusion The minute detail of normal physiologic of the ears is unsound and somewhat laugh- motion is best left for the classroom and per- able." Surely they would not use a dead fence sonal instruction. It can be found in the text- post as the criterion of the motion of a live book.1 Suffice it to say that in external rota- tree, swaying in the breeze with the sap still tion, minute though it be, the petrous ridge in it. How could the great variation in ear po- turns about an arbitrary axis running from sition be explained other than to say that the jugular surface to the petrous apex. This perinatal influences mold the infants cranium carries the superior border of the petrous por- and so alter the position of the temporal cart- tion anterolaterally toward the periphery. At ilages, which soon ossify? the same time the superior border of the Generally speaking, with brachycephalic squama moves anterolaterally, the tip of the heads the temporal bones are physiologically in zygomatic process moves inferiorly, but both external rotation so that the ears protrude the mastoid process and the mandibular laterally (Fig. 2). This is not always true, move posteromedially. Internal rotation is in however. With dolichocephalic heads the tem- the opposite direction. Studies of cranial mo- poral bones usually are in internal rotation tion3 may be found in the literature. with the ears close to the head, but this also It must be emphasized that motion is mi- may vary. These characteristics can be seen nute, but it can be recognized readily by a easily. The more minute variations, usually physician trained in the concepts of osteo- with one ear rotated slightly internally and the pathic medicine in the cranial field. Pathologic other slightly externally, are common. They change occurs when the physiologic motion is may be obvious to the trained observer, or they disturbed, limited, or prevented completely. may be perceived only by astute palpation. This often occurs in the perinatal period. Ob- They are always meaningful, reflecting plagio- viously, with the rapid growth of preosseous cephaly resulting from trauma. A contributing elements, membrane and cartilage, during that factor is found in muscular insertion. The time, such disturbances can be of great sig- number of muscles inserted into the temporal nificance, with distortion or retardation of de- bone is smaller than that of muscles that at- velopment, limiting of function, etcetera. tach to the sphenoid bone, but there is a con- Later in life trauma to relatively normal siderably increased degree of tension on the structures and certainly to those that have de- temporal bone because of the lateral position

Journal AOA/vol. 78, June 1974 827/91 Fig. 2. Observation diagnosis of the head. (I). The extreme flare of the ears denotes external rotation of the tenzporals from excessive sphenobasilar flexion. Flexion type head. (II). Close approximation of the ears sug- gests internal temporal rotation. Perhaps a brachycephalic type with sphenobasilar extension. Broad head but high vertex. Ear position might be due to bilateral intraosseons temporal lesions or plastic surgery. (III). Intern- al rotation of the left temporal and external rotation of the right, shown by the ears, means torsion or sidebend- ing rotation, probably the latter because of the exaggerated ear position. (IV). Retrusion of the lower jaw sug- gests external rotation of the temporals and a flexion base. The occipital sguama is angulated and there seems to be a vertical shift in the sphenobasilar symphysis. Reprinted from Magoun.

of the mastoid process. Pathologic change Baker reported scientific research demon- Not only malocclusion but a number of other strating slight but definite movement of the dental problems, such as temporomandibular temporal bones. His study was inspired by a joint pathology, are explainable on the basis personal experience with malocclusion. It sub- of the cranial concept, which sheds new light stantiated the assertion that abnormal posi- on their diagnosis and treatment. tion or lack of physiological motion of the tem- It is a well-known fact in osteopathic pathol- poral bone can lead to pathologic change. ogy that changes in the distance between the

828/92 origin and the insertion of a muscle have a factor. With external rotation of the temporal definite effect on physiologic function, as well bones, the temporomandibular fossae move as the position and mobility of the bones in- somewhat posteromedially, causing a bilateral volved. What is more common in the stress of backward shift of the lower jaw, which may modern life than muscular and fascial tensions result in overbiting. Conversely, internal ro- in the neck, usually more evident on one side tation of both temporal bones moves the fossae than the other? The temporal bone involved anterolaterally, which tends to cause protru- suffers as a result. sion of the mandible. If one temporal bone is The also suffer. Con- rotated internally and the other externally, sider the temporalis muscle, which arises from which is the common slight deviation, a lateral the and inserts into the coronoid shift of the symphysis menti to the side of process of the mandible. A slight shift in the posterior temporomandibular fossa will position of the temporal bone, such as might occur and will be evidenced by midincisal be induced by a long session in the dentists malalignment. For such a condition, the re- chair with the mouth open, can irritate this alignment of cranial bones would seem simpler muscle to produce painful spasms or trismus. and more logical than attempts to move the Equilibration of the teeth or depends teeth. Usually the cooperation of the ortho- on complete relaxation of the muscles of mas- dontist and the cranial expert is desirable. tication. Lack of it may be due to temporal A possible shift in the relative positions of malalignment and is not uncommon. Such per- the two temporomandibular fossae is an im- version of structure has a significant bearing portant pathogenic factor which has been on disorders of equilibration and may be their largely overlooked by the dental profession. essential component. This is equally true of the No end of arguments have arisen concerning rather obscure pathologic changes that in- the mechanics and functioning of the TMJ volve the temporomandibular articulation. It articulation. Its anatomy has been explored in certainly is a factor in malocclusion, as Bak- the minutest detail, but many well-meant con- er determined. Correction of any lesion of the clusions have been based on the false premise facial bones, or of the entire skull, for that that the two articulations are in a relative po- matter, is important, since the temporal bone sition of complete immobility. While other articulates with so many other important ones. types of trauma certainly exist, severe dental But position and normal physiologic motion of extractions account for structural distortion the temporal bone are of primary concern. of the temporomandibular articulation, with Bruxism is another minor affliction that reflex neuralgia induced in the capsular branch should be considered. The patient grinds the of the . teeth, either when awake or asleep, to the The disturbing phenomenon of a "popping dismay of those who hear it and the destruc- jaw" has been attributed to slipping of the tion of tooth surfaces. This often is attributed articular condyle over the posterior edge of to mental strain. Various appliances have been the cartilaginous disk and to its forward move- devised to restore equilibrium. However, the ment to hit the articular eminence. Regard- underlying cause is commonly a derangement less of the cause, normalizing the structure of the bones of the head, including the upper of the whole area is satisfactory therapy in or lower jaw and occlusal distortion. Tooth most cases. Proper positioning of the tem- grinding is the conscious or unconscious effort poral bone is paramount. on the part of the patient to restore proper Other problems associated with the temporal alignment of these bones, much as the baby bones include phenomena that may complicate with compression of the condylar parts resorts tooth extraction. According to Magoun, i Suth- to head rubbing or bumping because of discom- erland related that many years before he had fort in the back of the head and adjacent parts had a tooth pulled and experienced severe fa- of the neck. cial neuralgia, which was attributed to a "dry Other factors also should be considered in socket." After suffering for 2 weeks, he remem- the field of occlusal difficulties. Malocclusion bered that he had felt a sensation of separation may be due to shifting of the lower jaw for- behind the anesthetized area during the extrac- ward, backward, or sideways in relation to tion. Seeking to locate the place, he ran his the upper jaw, the position of which also is a finger back inside his cheek and closed his jaw

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on the finger back of the molars. A click fol- through the petrosal sinuses, the cavernous lowed, and there was complete relief from the sinus, and the orbital veins. Engorgement of neuralgia. This was one of the factors that the causes reflex pain over the frontal started Sutherland on his years of study and distribution of the first division of the fifth investigation of the cranial mechanism. He cranial nerve, which often is referred to mis- later determined that this had been an in- takenly as sinus headache. duced subluxation of the jugular surface of Much has been written° about involvement of the petrous portion of the temporal bone, the tenth cranial nerve, or vagus, with its which rests on and moves on the jugular tu- wide distribution. Gastric disorders are exam- bercle of the occiput. ples of its effects, although consideration also A much more serious subluxation can take could be given to other fields. The nuclei of place at the petrosphenoid articulation and the vagus nerve at the are can cause the horrendous discomfort of tic especially vulnerable, both perinatally and douloureux. This condition by no means is later. In many cases surgery for pylorospasm limited to this one cause, but all too often there in the newborn could be avoided by release is a history of traumatic tooth extraction. A of the occipitotemporal area. Peptic ulcers in full discussion is beyond the scope of this paper adults heal more quickly after correction of but can be found in the literature.1.5 this etiologic factor, probably the "unknown Sutherland5 has often stated that there need neurogenic factor" often mentioned. During be no failure in relief of migraine headaches if World War II a tank collided with an oak tree the temporal bones can be completely freed. and crew members were severely shaken up. This is a pretty big "if," in view of the multiple One of them, so his wife reported, went to 35 traumas that can involve this area. However, physicians, each of whom made a different the statement has considerable significance for diagnosis. Cardiospasm, smothering attacks, many sufferers. Despite emphatic pronounce- nervous prostration, anxiety neurosis, gastri- ments to the contrary, migraine is often trau- tis, insomnia, and fatigue were among them. matic in origin and is a reflex phenomenon. The old family physician came closest to the Personal experience is most convincing! A truth when he said: "I do not know what is fall on the ice as a child, striking the right oc- wrong but it is all the same nerve." He was cipitomastoid area, 40 years of misery with- correct. A temporal lesion of the vagus nerve out relief, and then a complete cure by cor- at the jugular foramen was responsible. rection of the temporo-occipital fixation would It may seem a little far-fetched to contend make a believer out of the most skeptical. The that some ocular problems can be caused by tragedy is that many otherwise competent lesions of the temporal bones, but this definite- physicians completely disregard the impor- ly is true.° Nystagmus in the newborn may re- tance of trauma and do not recognize plagio- sult from involvement of the vestibular ap- cephaly in patients with migrainous condi- paratus. It should be remembered that the tions. eighth cranial nerve traverses the petrous Tension headaches always are accompanied portion of the temporal bone by way of the with contraction of cervical muscles, especially internal acoustic meatus. Because of the close of those that attach to the mastoid processes. adherence of the dura mater along sutural Correction of lesions of cervical vertebrae may lines and in the sleeves surrounding nerves be futile if the base of the skull, and particular- as they exit through foramina, a slight mal- ly the occiput and temporal bones, remain in alignment of the temporal bone can cause lesion. The intimate relations of these bones pressure and fluid stagnation to interfere with to the muscles and fascia cannot be ignored. nerve function. The nystagmus accompanying Congestive headaches often are attributable Menieres disease could have a similar cause. to this same syndrome, because of retarded Clinical experience has proved that strabis- venous drainage through the jugular foramen. mus likewise may be associated with tem- Venous back pressure is transmitted directly poral lesions.° All of the extrinsic muscles of

830/94 the eye are vulnerable, not directly but through variety of organs and systems. This makes their nerve supply, the third, fourth, and sixth the diagnosis difficult and the real cause "hard cranials. These leave the midbrain and pass to find."7 forward along the side of the body of the It is not the purpose of this paper to cate- sphenoid bone in close relation to the forward gorize all the causes of either dizziness or ver- reaches of the tentorium cerebelli and partic- tigo, nor to list the usual methods of diagnosis ularly that portion called the petrosphenoid and treatment. Diagnostic clinics specializing ligament. The sixth nerve to the external rec- in this malady take 41/2 days to run all the re- tus muscle is especially subject to pressure quired tests. Even then patients may suffer symptoms, and its release can mean restora- from "conditions that are vague and inde- tion of function and muscle balance if the terminate." When the results of caloric and condition is not too far advaced.6 audiometric tests are normal, the term "idio- Obviously there are other causes for the con- pathic" is used. In the presence of such un- ditions mentioned here. Normalization of the certainty it would seem reasonable to explore position and motion of the temporal bone is a new approach, which has proved to be the not a cure-all, but it has been overlooked too answer in many cases. It can be said unequi- long in the art and science of medicine. vocally that the majority of patients with Problems relating to the middle and internal problems in equilibrium belong in the category ear also may be due to abnormalities in the po- of temporal bone disorientation. sition or motion of the temporal bone.° Of all The force of gravity dictates that a per- the varied symptoms confronting the physi- son must be equipped with an equilibratory cian, dizziness and vertigo are among the most mechanism that will inform him of his spatial common. They also present "one of the most relations with the world he lives in. This is lo- difficult problems in diagnosis and treatment," cated in the petrous portion of the temporal according to Wolfson. ? Part of the confusion bone, a sac filled with lymph. Into this sac, arises because dizziness and vertigo frequently rigid, hairlike processes project and are con- are used as synonyms and should not be. In nected with nerves that register pressure both conditions the manifestations are merely changes associated with changes of position. the symptoms of underlying malfunction and The conformation of the not a disease as such. The hallucination of mo- in three planes records motion in any direc- tion is common to both. The term dizziness tion. Motion in any one of these planes will should be used only for seeming motion within bend the sensory hairs backward because the head, such as light-headedness, unsteadi- the fluid lags behind the motion. With a sudden ness, or faintness. The many manifestations of stop, the fluid motion continues, in an attempt vertigo, on the other hand, may be either ob- to catch up, and the sensation that the en- jective, with seeming movement in the envi- vironment is moving results. Seasickness is ronment, or subjective, with a sense of per- merely chaos in these canals, with severe dis- sonal motion. turbance in nerve impulses and the well-known Such phenomena are common. The child at results. play spins around and falls down. The would- Some significance must be attached to the be aviator fails to pass the whirling test. The facts that dizziness or vertigo often follows tourist draws back from the edge of the tow- trauma to the ear or the neck and that patients er. The storm at sea or consumption of too complain of fullness in the ear, otherwise de- much alcohol may provoke a vigorous attack scribed as deep pressure. In dental theory mal- of vertigo. occlusion and temporomandibular dysfunction Vertigo may be divided into two main types, have been linked to the syndrome. Emphasis that caused by lesions of the central nervous has been placed upon positional vertigo, which system and that which is attributable to pe- occurs only when the head is turned to the ripheral factors. More than 40 forms of ver- "critical position." The overlooked cause is tigo have been described in relation to a wide suggested by this theory. It is rather simple

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but certainly logical to assume that Nature acteristic nausea, deafness, headaches, and intended that the two organs of equilibrium tinnitus, some patients have been able to func- be exactly oriented. If the right vestibule re- tion for increased periods without attacks ports motion differing from that reported on when the position and motion of the temporal the left, the reflex mechanism for the control bones have been normalized. Taking the pres- of position is thrown off balance and confused, sure off the ganglia of the vagus at the jugular as is the patient. Disturbances of the temporal foramen reduces nausea. Nerve deafness can- bones, containing the organs of equilibrium, not be overcome, but catarrhal deafness may do just that. be lessened. With a stopped-up condition of Unequal tension in the myofascial structures the eustachian tube, the blood vessels in the of the neck is common, perhaps from right walls of the absorb the oxy- handedness or from practices such as "cud- gen, creating a partial vacuum and resulting dling" the telephone or sleeping on the face hearing difficulty. Since the tube hangs be- with the head turned to one side. An excessive neath the temporal bone, the normalization pull on one side of the cervical musculature of the whole mechanism improves nerve con- can produce internal rotation of the temporal trol and circulation. bone on that side and disorientation of the The middle ear is essentially a nasal sinus. two organs of equilibrium. Dizziness results It is lined with ciliated epithelium, which, and may not subside until the structure is cor- with the constant secretion of mucus and the rected. Many persons have only a slight abnor- waving of the hair cells, acts as a conveyor mality that shows up in extreme conditions. belt to remove all foreign matter along the Candidates for the Air Force may pass a phys- tube and into the nasopharynx. Its lateral bony ical examination with perfect results but still third remains open at all times, but the me- fail the whirling test, from which they cannot dial two-thirds normally open and close with recover quickly enough. In World War II some each swallow or yawn. However, this cartilag- of these men sought corrective measures from inous portion can be twisted by lesioning of physicians in the cranial field and were accept- the temporal bone. The stagnation of disturbed ed afterward. ventilation and drainage makes it a culture McCabe has taken a backdoor approach to medium for infection. This explains why one the problem by what has been called the "con- middle ear becomes infected while the other frontation method."9 In this method the patient does not. Allopathic thinking has never ex- is instructed to take measures that exaggerate plained why this happens. The fact that struc- the symptoms in the hope of increasing toler- ture governs function gives the answer as well ance and thus remedying the situation. His as a logical approach to treatment, along with explanation to patients, according to Medical whatever other therapeutic measures may be World News,' is that they have a disease of necessary. The eustachian tube is more vulner- "the balance center" and that "the two part- able in the young than in older persons be- ners which normally work together in the bal- cause of its more horizontal position. Correc- ance center are no longer sharing the load tive measures applied to the temporal bone equally and must be forced to confront each offer a potent method of treatment of otitis other." His method would seem to be a rather media in little children. crude way of attempting to coordinate vesti- Tinnitus has a variety of causes, one of bular activity when there is a relatively sim- which definitely is the condition of the eusta- ple and logical method of gently realigning chian tube.° Fixed internal rotation of the the temporal bones in their proper orientation temporal bone will tend to keep the cartilag- and so normalizing the mechanisms. inous portion of the tube closed and produce a In the experience of those who have mastered high-pitched sound. The opposite position with the cranial approach to disease of this sort, the tube held open produces a low roar. It the results have been most satisfactory. seems logical that the noise is produced by the Even with Menieres disease, with the char- blood rushing through the carotid

832/96 around the elbow bend within the substance of landed on his head on the concrete below. The the petrous portion of the temporal bone. Only broken sidewalk, the pool of blood, and the a thin, osseous plate separates it from the inert, scalped body suggested a DOA to the internal ear. In normal conditions no sound is ambulance crew. The surgeon who sewed back heard, but a conch shell held to the ear makes the scalp said that he did it to save the under- a closed box of the area and one "hears the taker the trouble. And his assessment of "hell surf roar" with the heart beats. be nothing but a vegetable in case he survives" In all involvements of the eighth cranial —all of these dire predictions proved false. nerve it must be remembered that dural ten- The almost complete recovery of this physician sion about the , in- was a modern miracle performed by experts in duced by plagiocephaly in this area, may af- cranial ostepathic medicine. fect the cochlear branch and thus the hearing.6 Embryologically, the vault develops in the The collects the vibrations. The mid- membrane for accommodation to the cartilag- dle ear amplifies them into lymph waves, and inous base. That relation persists to some de- the inner ear transforms these into nervous gree throughout life. Remarkably there seem- impulses that are translated into consciousness ed to be no fracture in this case. The force of sound at the temporal cortex on the oppo- of the fall on the parietals was absorbed to site side of the head. Structural deviations thus some degree by the resilience of the bone, by have ample room to operate. the wide, overlapping bevel of the parieto- The endolymphatic mechanism does not squamous sutures, by the temporal bones mov- communicate directly with the subarachnoid ing laterally into eternal rotation, and by the space. However, a functional relation exists firmness of the skull base, which passed the between this and the . This impact on down through the neck and thorax. is comparable to the relation between the Situated between the occiput and sphenoid, the bloodstream and the mercury manometer, be- petrous or rock-like portions of the temporal cause the and duct lie with- bones are the strongest of any part of the in dural folds around the vestibular aquaduct. skull. They stood firm. Thereafter, expert With every fluctuation of the cerebrospinal hands were able to replace the distortion of fluid, abnormal or otherwise, there will be a the container for the central nervous system— concomitant wave in the that aug- for an unbelievable recovery. ments fluid movement in the internal ear. Traversing the body of the temporal bone Comment with the eighth cranial nerve is also the se- Correction of structural deviations of the venth nerve, which finds exit through the temporal bones calls for training and personal stylohyoid foramen to supply the face. The instruction in the intricacies of the cranial usual disturbance is Bells palsy, a relatively mechanism, but detection of slight distortions common affliction of greater or less severity de- or lack of motion is somewhat easier. With the pending on whether the inflammation in the patient supine, the fingers are interlaced loose- nerve is up in the narrow confines of the facial ly beneath the occipital squama, with the the- canal or merely outside. Normalizing the phy- nar eminences resting lightly on the mastoid siology of the temporal bone usually is suc- portions of the temporal bones and the thumbs cessful in treating this malady. along the mastoid processes. One must not Whether a trouble maker or not, the tem- be heavy-handed. The axis from the jugular poral bone can do an heroic job of maintain- surface to the petrous apex should be kept in ing the continuity between the sphenoid in mind. Careful sensing of the position of the the anterior part of the head and the occiput inert thumbs must be done with the hands in the posterior part, help absorb traumatic completely relaxed. Should one thumb seem to shock, and still stand firm. A distinguished slant upward and inward while the other member of the profession fell from a second seems to slant downward and forward, the story balcony when the railing gave way and inference would be that the temporal bone is

Journal AOA/vol. 78, June 1974 833/97 Temporal bone

positioned in relative internal rotation and the It is not my intention to suggest that osteo- other in relative external rotation. But the pathic correction of plagiocephaly is a cure-all approach must be in a completely relaxed or that cranial lesions are the only cause of manner, since tension or force will mask the disease. Judging from the experience of those findings and defeat the purpose of the exam- who have used this method for many years, ination. this type of work offers a logical and effective Having determined this difference by pal- approach to solving many problems In various pation or position, the physician should pal- fields of practice. In the cranium as elsewhere, pate for motion. Motion is definite but minute structure governs function. in amount, and it can easily be obscured or In a JOURNAL OF THE AMERICAN OSTEOPATHIC missed unless palpation is done correctly. ASSOCIATION editorial, Northup° said: "If ever From the same relaxed hand position, one there was a time for manipulative measures to middle finger is rolled on the other, gently be described, demonstrated, and written about, and slowly, first in one direction and then in it is now." And this most certainly applies as the other, in minimal amounts. The motion much as anywhere in the cranial field, of the hands is barely visible and follows the physiologic axes of the bones. While no direc- Summary tive movement is given through the thumbs, Osteopathic medicine in the cranial field in- their change in position will passively initiate volves all of the more important bones of the the slight external rotation possible in one skull, but only the temporal bone is considered temporal bone and, at the same time, the slight in this discussion, with the possible effects of internal rotation possible in the other. The malposition or disturbed physiologic motion. freedom of motion in alternating directions is It should be of special interest to the general compared, with time always being allowed for practitioner or the specialist along certain the inertia of structure to be overcome as the lines. mechanisms carries on. Pediatricians should recognize the frequen- It is common for one temporal bone to ro- cy of neonatal plagiocephaly, which is so tate in one direction more freely than in the quickly incorporated into the rapidly growing opposite direction, in which slight or marked new life. In the eye, ear, nose, and throat field resistance is encountered. The bone is lesioned it deals with such problems as disturbances in the direction toward which it moves most in equilibrium, strabismus, nystagmus, otitis freely. The lesioning occurs at a lifelong syn- media, Bells palsy, and others in which clin- chrondrosis, the pivot of the jugular process ical experience has shown a link with temporal of the occiput and the jugular surface of the bone disturbances. The areas involved in the temporal bone, unless trauma dictates other- distribution of the tenth fall in- wise. to the same category. The overlapping fields of Methods of correction can be learned only malocclusion, prob- through personal coaching over a considerable lems, popping jaw, bruxism, trismus, and the period. However, the operator does not do the like suggest advantageous cooperation with actual correcting. He merely holds the mecha- the dental profession. Long-standing condi- nism in whatever position is most favorable tions erroneously attributed to other causes or for the innate forces within the body, such as presenting an enigma are elucidated. The list the pull of the meninges or the fluctuation of is by no means complete. the cerebrospinal fluid, to restore normality. A dramatic case is cited in which the pa- As elsewhere in the body, Nature tends to re- tient, an osteopathic physician, after an un- store normal relations when restrictions are believable recovery from a two-story fall made removed. Recent lesions may be corrected the statement: "To scoff at the clinical evi- easily, but those due to severe trauma or the dence of functional restoration wrought by toxemia of a previous infection can be highly such cranial techniques is to deny the right resistant and difficult to correct. to think."

834/98 (Submitted for publication in September 1972. Updating, as neces- 1. Magoun, H.I.: Osteopathy in the cranial field. Ed. 2. Suther- sary, has been done by the author.) land Cranial Teaching Foundation, Meridian, Idaho. 1966 2. Sutherland, A.S.: With thinking fingers. The story of William Garner Sutherland, D.O.. D.Sc. (Hon.). The Cranial Academy. Kansas City, Mo., 1962 8. Frymann, V.M.: A study of the rhythmic motions of the living cranium. JAOA 70:928-45, May 71 4. Baker, E.G.: Alteration in width of maxillary arch and its relation to sutural movement of cranial bones. JAOA 70:669-64, Feb 71 5. Sutherland, W.G.: Dental traumatic cranial lesions. In Con- tributions of thought. Collected writing., edited by A.S. Sutherland and A.L. Wales. Sutherland Cranial Teaching Foundation, Meri- dian. Idaho, 1967 6. Magoun, H.I.: Entrapment neuropathy in the cranium. JAOA 67:648-52, Feb. 68. Entrapment neuropathy of the central nervous Dr. Magoun is a trustee in the Suther- system. II. Cranial nerves I-IV, VI-III, MI. JAOA 67:779-87, Mar land Cranial Teaching Foundation, 68; III. Cranial nerves V, IX, K, XL JAOA 67:889-99, Apr 68 Inc., Meridian, Idaho. 7. Wolfson, R.J.: Vertigo. Recent advances in etiological diag- Dr. Magoun, 460 Goddard Court, Rio nosis and management. DO 10:112-8, Jul 70 Grande Estates, Belen, New Mexico 8. Pierce, R.H.: Dizziness. Diagnosis and management. DO 8: 87002. 108-17. Dec 67 9. Movement to end vertigo. Med World News 11:28A, 12 Jun 70 10. Northup, G.W.: Editorial. A problem with low backs. JAOA 70:1262-8, Aug 71

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