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OTITIS MEDIA - Ear InfectionsTwo hundred pediatricians and two hundred chiropractors that were selected were
surveyed to determine what, if any, differences were to be found in the health status of
their respective children as raised under the different health care models. The
'chiropractic' children showed a 69% otitis media free response, while the 'medical'
children only had a 20% otitis media free response. 93% of all episodes of otitis media treated with chiropractic care improved, 75% in 10
days or fewer and 43% with only one or two treatments. This study's data indicates that
limitation of medical intervention and the addition of chiropractic care may decrease the
symptoms of ear infection in young children. The author has presented a case series of five patients with chronic recurrent otitis
media who underwent a program of chiropractic case management, including specific spinal
adjustments. All patients had excellent outcomes with no residual morbidity or
complications. The associated morbidity of current medical and surgical options for
otitis media with effusion (OME), coupled with a lack of rigorous experimental designs in
some reports, further necessitates the exploration of alternative approaches to case
management. Only 1 in 8 children with ear infections benefit from
antibiotics according to a report in the New England Journal of
Medicine. In the study, researchers found that most subjects who
received placebo recovered just as quickly as subjects taking prescription
antibiotics. Within one week 81% of placebo subjects and 94% of antibiotic
recipients had recuperated. Lead author, Dr. J. Owen Hendley, shares the same
concerns about prescription side effects and antibiotic resistance that
chiropractors and other holistic health-care professionals have worried about
for decades. He advises physicians to prescribe antibiotics for ear infections
sparingly. He suggests practitioners wait 48 to 72 hours before administering
drugs as ear infections often mend on their own. Based on these findings, the authors conclude that there appears to be no basis to the
commonly held belief that swimming may induce or exacerbate otitis media. In fact, the
converse may be true. Inflammation in the nasopharynx and the pharyngeal portion of the eustachian tube was
considered to be closely related to the tubal constriction, which represents a
considerable part of the cause of tubal ventilatory dysfunction in otitis media with
effusion. Musculoskeletal eustachian tube dysfunction is an important etiological factor for
otitis media. The eustachian tube dysfunction manifests primarily by poor ventilation from
the nasopharynx to the middle ear, by allowing sniff induced negative pressure in the
middle ear. In cases of secretory otitis media it is generally agreed that the usual basic factor
is an inflammatory process with functional or mechanical obstruction of the eustachian
tube. Tympanostomy treatment in cases of chronic otitis media does not eliminate the
dysfunction of the eustachian tube, but only serves to substitute tubal function. Only 4% of the 222 infants with recurrent acute otitis media developed chronic otitis
media with effusion and an additional 12% continued having recurrent episodes. Spontaneous
recovery from recurrent acute otitis media is common with increasing age. Thus, until
reliable causal evidence between recurrent otitis media and developmental disability is
presented, chemoprophylaxis or tympanostomy tubes seem superfluous for most infants after
the age of 16 months. Myringotomy and tympanostomy with tube implantation are frequently both ineffective and
expensive. In a study of 6611 children, making generous clinical assumptions, 41% of
the proposals for these reasons had appropriate indications, 32% had equivocal
indications, and 27% had inappropriate ones. About one quarter of tympanostomy tube
insertions for children in this study were proposed for inappropriate indications and
another third for equivocal ones. It is concluded that the use of ventilation tubes in children with primary secretory
otitis media is not justified. Observation has shown that only a small proportion will
require surgical treatment of the middle ear. A ventilation tube may be indicated in order
to combat hearing loss, but it should be borne in mind that its use involves a high risk
of complications and sequelae which may result in chronic middle ear disease.
Medical treatment failures probably already surpass eustachian tube dysfunction as the
most common reason for tympanostomy tube insertion. Antibiotic treatment of otitis media is no more effective than placebo, and increases
the risks of reoccurrence. To determine the effect of antibiotic treatment for acute otitis media in children six
studies of children aged 7 months to 15 years were reviewed. 60% of placebo treated
children were pain free within 24 hours of presentation, and antibiotics did not influence
this. Antibiotics seemed to have no influence on subsequent attacks of otitis media
or deafness at one month. Antibiotics were associated with a near doubling of the
risk of vomiting, diarrhoea, and/or rashes. Early use of antibiotics provides only
modest benefit for acute otitis media: to prevent one child from experiencing pain by 2-7
days after presentation, 17 children must be treated with antibiotics early. Otitis media with effusion usually resolves spontaneously. The available literature
indicates that antibiotic treatment has at most a short-term effect. Therefore it is not
indicated for the treatment of otitis media with effusion. Antibiotics are not the best treatment for middle ear infections (otitis media) and
doctors should stop routinely prescribing drugs for them. Records from 2,089 otitis media patients were examined to determine incidence and
treatment success. There was no difference in success rates between antibiotic and no
antibiotic therapies. Most clinical trials comparing the efficacy of different antibiotics have failed to show differences in clinical efficacy. To date, no definitive trials of bacteriologic efficacy in children have been published. Cohen R. The antibiotic treatment of acute otitis media and sinusitis in children. Diagn Microbiol Infect Dis 1997; 27(1-2):35-9 / Medline ID: 97272394 In a review and critical appraisal of the literature on antibiotic therapy for acute
otitis media in children between 1939 and 1991, poor evidence supported the routine use of
antibiotic therapy. This approach cannot be recommended for children 2 years and
younger because this age group has been excluded from most studies. Few issues in clinical medicine are as controversial as the efficacy and risks
associated with antibiotic treatment of otitis media. Recent studies document the
emergence and rapid spread of drug-resistant streptococcus pneumoniae in acute and
unresponsive otitis as well as persistent effusions and chronic suppurative otitis. It is
best to avoid the antibiotic treatment dilemma as much as possible by not over diagnosing
otitis media. Oral decongestants are ineffective in treatment, or prevention, of otitis media in
children. While once-a-day dosing was equivalent to twice-a-day dosing for amoxicillin
prophylaxis, there was no benefit of amoxicillin prophylaxis compared with a placebo
control in preventing new AOM episodes. Because of the potential of excessive antibiotic
use to promote the acquisition of resistant pneumococci and the lack of effectiveness in
this trial, routine use of amoxicillin prophylaxis should be discouraged. Amoxicillin with and without decongestant-antihistamine combination is not effective
for the treatment of persistent asymptomatic middle ear effusions in infants and children. Patient recovery from otitis media seemed not to be influenced by either the type of
antibiotic given, or the period of time for which it was given, except that the rates of
recovery were better in patient's of all age groups who did not receive any antibiotic
therapy at all. Within a prospective group study of five practicing otorhinolaryngologists,
conventional therapy of acute otitis media in children was compared with homeopathic
treatments. Group A (103 children) was primarily treated with homeopathic single remedies.
Group B (28 children) was treated by decongestant nose-drops, antibiotics, secretolytics
and/or antipyretics. Comparisons were done by symptoms, physical findings, and duration of
therapy and number of relapses. The children of the study were between 1 and 11 years of
age. The median duration of pain in group A was 2 days and in group B 3 days. Median
therapy in group A lasted 4 days and in group B 10 days. Antibiotics were given over a
period of 8-10 days, while homeopathic treatments were stopped after healing. In group A
70.7% of the patients were free of relapses within 1 years and 29.3% had a maximum of
three relapses. Group B had 56.5% without relapses and 43.5% a maximum of six relapses. Of
103 subjects 98 (95.1%) responded solely to homeopathic treatments. No side effects of
treatment were found. Back to TopQuestions
Back to TopQ: I have a 21 month old baby who has continuous
ear infections and may face the possibility of having tubes placed in his ears. Have you
been successful with this type of condition? R.W. in GA Back to TopArticles
Otitis Media in Young ChildrenBy: Chris L. Hendricks, D.C. and Susan M. Larkin - Thier, D.C ABSTRACT KEY WORDS: Antibiotic therapy, chiropractic, myringotomy,otitis media. INTRODUCTION Currently, antibiotic therapy is the first step in the standard medical approach.[11] [12] Myringotomy and tympanostomy tube placement are more radical procedures employed for non-responsive cases.[13] [14] Unfortunately, these surgical procedures frequently are both ineffective and expensive.[15] [16] The annual cost of diagnosis and treatment of children with otitis media reaches nearly $2 billion per year.[16] Chiropractic has been ignored in the literature as a viable treatment for otitis media. There is a direct relationship between the middle ear, the tensor veli palatini muscle and the superior cervical ganglion. Employing the basic tenets of the science of chiropractic, it is logical to hypothesize that doctors of chiropractic may be able to effectively treat otitis media. ANATOMY OF THE EAR THE EXTERNAL EAR The tympanic membrane is divided into two parts: the pars flaccida (located in the superior aspect) and the remainder of the membrane, the pars tensa.[19] The manubrium, or handle of the malleus attaches to the center of the tympanic membrane, drawing it inward, which forms a concavity on the tympanic membrane's outer surface.[17] [18] The center of this concavity is referred to as the Umbo. The cone of light, a landmark of the normal tympanic membrane, is visualized in the anterior inferior quadrant, while the lateral or short process of the malleus is located in the posterior superior portion of the pars flaccida. [8] [17] [18] [20] Posterior and parallel to the posterior to the upper portion of the handle of the malleus is the long process of the incus. The head of the stapes is inferior to the incus. THE MIDDLE EAR
The middle ear or tympanic cavity is an epithelial lined cavity, hollowed out of the temporal bone. The eustachian tube, lined with ciliated columnar epithelium containing goblet cells, connects the middle ear cavity to the paranasal sinuses.[21] [22] The paranasal sinuses connect with the nasal cavity via the normally patent ostium of the eustachian tube.[23] The middle ear cavity and the sinuses constantly accumulate transmucosal exudates and require a mechanism to clear this fluid.[21] [24] The entire epithelial lining is ciliated so that, under normal circumstances, ventilation and drainage readily occur through the ostium. If the ostium is even partially blocked, as occurs in pathologic conditions, such as sinusitis, the common cold and sore throats, accumulations of fluid with mucosal inflammation and/or infection will result. [3] [21] [24] [25] [26] When the eustachian tube functions normally, there is a clearance of fluid, exchange of gases and equalization of pressure. [24] [27] This occurs by contraction of the tensor veli palatini muscle. [16] [18] [21] This muscle is innervated by the mandibular branch of the trigeminal nerve with motor fibers. These fibers exit the middle cranial fossa through the foramen ovale and unite outside the skull, forming portions of the superior cervical ganglion located between the C-1 and C-4 nerve roots. [5] [17] [26] [28] [29] The eustachian tube in infants is nearly horizontal, and slowly acquires an angle of 45° by the time the child reaches the age of seven.[8] The ostium very closely approximates the lymphatic tissue of Waldeyer's Ring. As the child grows and the eustachian tube assumes a greater angle, more space develops between the ostium and this lymphatic tissue.[8] [20] However, during frequent upper respiratory infections in early childhood, the lymphatic tissue hypertrophies and may block the eustachian tube opening. [30] [31] This makes ventilation of the middle ear impossible and provides a simple explanation for the occurrence of otitis media. PATHOPHYSIOLOGY Acute Otitis Media Diagnosis of acute otitis media depends on the appearance of the tympanic membrane, patient presentation and /or a recent history of upper respiratory infection. [8] [25] [35] [36] The tympanic membrane may appear either red or yellow, depending upon the amount of fluid present in the middle ear. In the early stages, bulging may be limited to the pars flaccida, but later the entire tympanic membrane bulges outward giving it a doughnut like appearance.[8] [20] [35] The major clinical presentations of acute otitis media are earache, fever and bulging of the tympanic membrane. Otitis media caused by H. Influenzae more often presents with a low grade fever, minimal pain and only a slightly bulging tympanic membrane. If the tympanic membrane is inflamed but flat, the exudate is most probably sterile. If only the pans flaccida is bulging, a 20 percent probability of bacterial infection exists. Beta- hemolytic streptococcus is frequently the organism present in cases where there is a spontaneous rupture of the tympanic membrane. [8] [20] [35] [36] The drugs of choice are broad ranged antibiotics (e.g. Ampicillin, Amoxicillin, Erythromycin, Cefaclor and Sulfonamide) for a period of ten days. Sterile effusion will not respond to antibiotics. If there is not improvement within 36 hours antibiotics should be discontinued. [37] [38] Chronic Otitis Media Chronic otitis media. unlike the acute variety is usually clinically asymptomatic.[39] Permanent hearing loss is commonly encountered although its gradual onset frequently goes unnoticed. The patient may complain of fullness in the ear or the sensation of "speaking in a barrel". This type of otitis media is closely associated with learning disabilities. The child frequently presents as agitated. irritable or unable to concentrate in school. [43] [44] [45] [46] [47] [48] Upon examination. the tympanic membrane may appear mildly infected and dull, or it may appear normal in the resolution stage there may be fluid levels or air bubbles seen on the tympanic membrane indicating a return of eustachian tube function.[3] [8] CONVENTIONAL MEDICAL TREATMENT In the 195O’s and early 1960’s, the practice of lancing the tympanic membrane (myringotomy) was the procedure of choice. [49] [50] While somewhat successful, this surgery addressed only half the problem of otitis media. Following the myringotomy, fluid is released for a short period of time, but the opening created by the procedure closes quickly, allowing fluid build up. Even the short period of ventilation did not seem to have any effect on the negative pressure vacuum created by the eustachian tube dysfunction. [51] In the mid 1960’s tympanostomy tubes were introduced.[49] [52] In the same surgical procedure practiced today, the tympanic membrane is incised and a drainage tube inserted and secured. The tubes are generally held in place for a period of six months then removed if they have not been spontaneously aborted. During the time the tympanostomy tubes are in place, the patient experiences a decrease in symptomatology. [2] [8] [13] [14] INEFFECTIVENESS OF MEDICAL TREATMENT The side effects of antibiotic usage include allergic reaction (e.g. hives, shortness of breath, anaphylactic shock). gastrointestinal upsets (e.g. nausea, vomiting, diarrhea), superimposed yeast infections (caused by candida albicans resulting in thrush and vaginitis), and finally, an increase in tolerance of the child to antibiotics, rendering the drugs ineffective at some point. Some sources believe that the increased frequency of otitis media noted in this decade is due to antibiotic resistance. [8] [20] [54] Children through the age of two who have had two or more episodes of acute otitis media in the same ear are considered to be appropriate candidates for myringotomy. [13] [14] Children over two who have had three episodes of otitis media in the same ear are considered to be candidates for myringotomy with the placement of ventilating tubes.[55] [56] However, 98 percent of children who have had myringotomies will experience a recurrence of effusion buildup after 53 days, and 75 percent of children with ventilation tubes will experience a recurrence after 223 days. [15] [57] [58] Evidence suggests short term adverse effects of myringotomy and tympanostomy tubes include the occlusion of the incision before pressure equalizes and the displacement of tubes, requiring a second surgical placement.[58] There is mounting evidence that these surgical procedures produce adverse effects which will show up years later.[55] [56] [57] [58]. Forty percent of the cases of the insertion of tympanostomy tubes have resulted in permanent structural damage to the tympanic membrane, such as the atrophy of the tympanum presenting five or more years later, Twenty-five percent of the persons subjected to this procedure for the prevention of deafness experienced total hearing loss seven to ten years later.[5] CONCLUSION Motor nerve fibers can be traced from the tensor veli palatini, to the superior cervical sympathetic ganglion. The cervical plexus receives these fibers between the spinal levels of C-l through C-4. Subluxation’s affecting these levels may be responsible for deranged function of the tensor veli palatini muscle resulting in the pathological response of otitis media. Restoring the spine to its proper alignment through chiropractic care should result in the return of normal nerve supply to the tensor veli palatini muscle and ultimately normal function of the eustachian tube. A controlled clinical trial of the efficacy of chiropractic care on otitis media is indicated to verify this conclusion. Such a study is planned by the authors and should begin later this year. ACKNOWLEDGMENTS REFERENCES
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© 1996-2003 Craig M. Anderson, D.C.
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