Current thinking in the management of Otitis Media
Part 2

It appears that the Eustachian tube has a key role in the pathogenesis of OM. This is mostly due to the dysfunction or inappropriate function of the tensor veli palatini (TVP) muscle, which is responsible for the opening and closing of the Eustachian tube and this in turn may be due to the delayed nerve supply to this muscle. In a normal situation, fluid is drained from the middle ear, but in an abnormal situation, fluid is not drained and remains in the  middle ear and that initiates an inflammatory response from the middle ear [1,3,4,6,7]. 
The allopathic approach to the treatment of Acute Otitis Media has been to prescribe antibiotics and it’s currently still the same. According to  CPS (Canadian Paediatric Society), AOM’s symptoms will resolve faster if antimicrobials  are prescribed. However, a watchful waiting or ‘wait and see’ (WAS) with analgesia is recommended by CPS, American Academy of Pediatrics, and the Academy of Family Physicians, as not all children with AOM should receive immediate treatment with antimicrobial agents. In fact, a randomized control trial of 283 children found no difference in fever, otalgia (ear pain) or further visits to medical provider between WAS group and standard prescription group. The watchful waiting approach recommended by CPS is appropriate for a child who is older than 6 months of age, doesn’t have immunodeficiency, chronic cardiac or pulmonary disease, anatomical abnormalities of the head or neck, a history of complicated OM, Down syndrome, and presents  with mild signs and symptoms (fever <39, mild otalgia). The watchful period is for 48 to 72 hours during which no antimicrobial agents should be used. Usually when this course of action is taken,  the symptoms take longer to resolve, but at the end, only one third of children may need the use of antibiotics.  In case of children with severe symptoms like fever (>39) or toxic appearance, watchful waiting is not recommended. For the initial treatment of antibiotics amoxicillin is used because it is well tolerated, reasonably priced, and can achieve high levels in the middle ear. The recommended daily intake is either a lower dose of  70mg 3x/day, or in cases where eradication of penicillin-resistant pneumococci   is desired, a higher dose of 90mg 2x/day is used. In the second line of treatment Cefprozil, Cefuroxime axetil, Ceftriaxone, Azithromycin, or Clarithromycin is used. Within one to two days of antibiotics intake symptoms should improve and eventually resolve within 2-3 days. However, certain microbial agents like beta-lactamase-producing Moraxella catarrhalis and Haemophilus influenzae may not respond to amoxicillin. In such cases, the antibiotic is changed to either amoxicillin/clavulanate or parenteral ceftrixone so that both penicillin-resistant Streptococcus pneumoniae and beta-lactamase-producing Moraxella catarrhalis can be targeted. [1,3,6,9,11,14].
There are also reasons to avoid the use of antibiotics. According to ACA, many cases of OM are not bacterial and overuse of antibiotics may lead to antibiotic resistant bacteria. Furthermore, some studies suggest that antibiotics are ineffective in treating OM and for every 17 children that are treated with antibiotics only one child can be prevented from experiencing some pain two days after presentation to pediatrician. In addition, antibiotics may involve serious side effects as studies have found that children are 4x as likely to develop asthma if antibiotics were used in the first year. Other risks associated with the use of antibiotics include diarrhea, Stevens-Johnson syndrome or anaphylaxis (an acute multi-system severe type I hypersensitivity allergic reaction). On the other hand, another study showed that in the Netherlands, where 30% of AOM cases are treated with antibiotics, the incidence of mastoiditis was twice as high as other countries where more than 90% of AOM cases were treated with antimicrobials. However, research indicates that due to the rare incidence of mastoidits, at least 2500 prescriptions would have to be filled to prevent one case.   [9,10,11,12].
The 2009 CPS statement also has some recommendations for parents that may reduce the risk for AOM in their children. Some of these recommendations are:
          Excellent hand hygiene
          Exclusive breastfeeding until at least three months of age
          If bottle feeding cannot be avoided, do not prop the bottle and use fully ventilated bottles
          Pacifier use in children younger than three years of age increases the risk for recurrent OM by up to 25%. The risk appears to be r                 related to the frequency of use
          Limiting daycare exposure for very young children decreases the risk of upper respiratory tract infection and therefore AOM
          Encourage childcare providers to develop and implement procedures for hand hygiene, as well as toy and environmental cleaning
          Not smoking
Furthermore, influenza vaccine is highly encouraged by CPS for healthy children older than six months of age and their caregivers, as influenza plays a role in the pathogenesis of AOM, and the killed influenza vaccine has been shown to provide some protection against AOM in toddlers [9].
The current allopathic treatment of Chronic Otitis Media or Otitis Media with Effusion is antibiotics, myringotomy, and tympanostomy tube insertion to drain the accumulation of middle ear fluids. However, the benefits of these treatments are heavily debated. According to ACA, in children younger than 3 years, tube insertions did not improve developmental outcomes. Other potential complications include risks of anesthesia, tympanic membrane scarring and hearing loss. In addition, the cost of the current allopathic treatments for OM is subject to a lot of criticism. A more cost effective treatment plan with decreased risk of side effects is strongly advised. Furthermore, guidelines published by the American Academy of Pediatrics (AAP)  and the American Academy of Family Physicians in 2004 states that diagnosis of AOM requires:
          1) A history of acute onset of signs and symptoms (fever, irritability, ear pulling)
          2) The presence of middle-ear effusion (confirmed by decreased mobility  of the tympanic membrane)
          3) Signs and symptoms of middle-ear inflammation
These guidelines give a structured approach to antibiotic use, with recommendations for wait and see prescription. However there are no recommendations for any other alternative treatment for AOM [1,3,6,9,11,13,15].
The ACA gives the following rationale for chiropractic care for OM:
          - Fluid in the middle ear cavity is drained through the Eustachian tube (ET)
          - The ET diameter is controlled by the tensor veli palatini (TVP), which is innervated by CN V (Trigeminal nerve)
          - There is a secondary regulation by the levator veli palatini muscle (LVP) and salpingopharyngeus muscle (SP), which are both                       innervated by CN X (vagus nerve)
          - An irritation of the superior cervical sympathetic ganglion secondary to a subluxation can have an affect of both CN V and CN X,                   which could lead to an increase in the tone of TVP, LVP, and SP and con consequently result in the constriction or closure of the                 ET
          - This will result in a buildup of fluid in the middle ear, which can be painful even when there is no infection
          - Eventually, the fluid will become infected with pathogen (viral or bacterial)
          - Antibiotics are mostly used at this stage, without addressing the underlying cause and consequently recurrent infections occur,                    which mostly leads to repeated course of antibiotics intake
          - The spinal and cranial adjustments remove the subluxation and therefore, relieve the ganglionic irritation and release the TVP                     spasm, which allows for the fluid to be drained through the ET
In an evaluation of chiropractic treatment for OM in children it was established that 67% of chiropractors use spinal manipulation therapy in their management, followed by dietary recommendations, soft tissue therapy, and supplements. Furthermore, according to the same report adjustment of C1 (Atlas) was performed in all cases of OM. Other RCT’s case series and case studies for over 450 patients support the theory  that chiropractic care can help children with OM. According to ACA, most cases resolve within 10 days, with fewer than 5 adjustments and only 1 to 2 treatments.  There are a number of studies published since 1996, as mentioned in the 2008 ACA statement, which emphasize the role of manipulative therapy, both chiropractic and osteopathic, in the treatment of OM [1,7,11].
The treatment tools and protocols for chiropractic care, as described in the 2008 ACA statement, are divided into the following details [11]:
          1) Manual Therapies
               a) Spinal adjustments with the focus being on the occiput
               b) Craniosacral therapy or other form of cranial work
               c) Soft tissue modalities
                    i.Lymphatic drainage
                    ii.Endonasal procedure
          2) Supplements
               a) Herbal ear drops to treat acute infections
               b) Immune support
                    i.Echinacea for bacterial infections
                    ii.Elderberry for viral infections
                    iii.Homeopathic immune tincture for babies
               c) GI support (probiotics and prebiotics), which is necessary for children who have been on antibiotics
               d) N-Acetyl Cysteine for mucus drainage
               e) Multivitamins, vitamin C, essential fatty acids (EFA’s)
          3) Parent education
               a) Reassure parents that most cases of OM in children can be treated without the use of antibiotics. In fact, there is a                                          spontaneous resolution in 81% of cases, which means that less than 20% actually need to be treated with antibiotics.                                  Chiropractic care can significantly increase the rate of resolution  without the need for antibiotics
               b) Educating parents about the role of fever in illness
               c) Inform parents about the ineffectiveness of the over-the-counter (OTC) cold and cough remedies for children
               d) Educate parents about some of the home remedies like humidifiers and warm compress over the ear
          4) Addressing underlying causes
               a) GI Dysbiosis or Leaky Gut Syndrome, which is a common sequela to antibiotic therapy and can lead to food allergies and                              chronic inflammation beyond the GI tract. It is diagnosed via stool testing
               b) Food intolerances and allergies
               c) Environmental allergies and Biochemical stressors like cigarette smoke, pets, household cleaning agents, laundry products,                          and etc can lead to chronic adenoid inflammation which can block the ET
          5) Nutritional deficiencies
               a) This is very common in the U.S. due to the standard American diet (SAD)
               b) Increase the consumption of fresh, organic foods like fruits, vegetables, whole grains
               c) Decrease simple carbohydrates, sodas, juices, food colorings, preservatives, and glutamates (natural flavor)
Based on the above treatment protocol, a typical treatment regime should consist of:
     - An initial twice per week treatment for two weeks
     - The treatment consists of spinal adjustment, craniosacral therapy, herbal tea drops in the acute cases, immune support in the acute           cases, nutrition program, parent education, determination of the underlying cause, if it can be done so from the history
     - Should the TM show no improvement after two weeks, endonasal procedure is recommended for once per week for 2-3 weeks
     - If there is a continued recurrence, inflammation, or effusion in the middle ear, underlying cause of the chronic inflammatory state               should be investigated
The osteopathic management and treatment of AOM can be dated back to 1928, when osteopathic manipulation treatment (OMT) by Galbreath was reported in the treatment of  catarrh (congestion) of the ear in the Journal of American Osteopathic Association (JAOA). The Galbreath technique is a soft tissue technique using passively induced jaw motion to effect increased drainage of middle ear structures and tonsillar congestion via the ET and lymphatics. This technique can also be thought to parents so that it can be performed daily in the treatment of chronic OM. Since then, many other studies and case reports have been published outlining OMT in the treatment of AOM in various osteopathic literature. A pilot study published in 2003 showed the study in which 57 children with recurrent AOM were randomized in an OMT or a standard treatment group. Patients in the OMT group had fewer recurrences, fewer surgical procedures, an increased frequency of improved tympanograms, and less antibiotic use than those in the standard treatment group. Since the 2004 Clinical Practice Guidelines by the AAP and AAFP, two clinical studies were published and demonstrated improved outcomes in children with recurrent AOM who receive OMT in addition to standard medical care. Another study from 2006 administered OMT on a weekly basis for 3 weeks to 8 children between the ages of 7 and 35 months, with a history of recurrent OM, and the subjects were followed for one year. The result showed that 5 subjects had no recurrence of symptoms during the year follow-up, one had four episodes of OM, one had a bulging TM, and one had a surgery. Furthermore, OMT has also been reported to provide immediate improvement in middle ear functioning in children as measured by tympanograms before and after the application of OMT. The objectives that are supposed to be accomplished by OMT can therefore be summarized as follows:
     - Improve lymphatic drainage from the inner ear
     - Decrease inner ear effusion
     - Improve function of the ET
     - Improve cranial and temporal bone motion
     - Decrease pain
Furthermore, OMT should only be applied to the structures surrounding the ear. It is also beneficial to improve motion of the suboccipital region, releasing the occipitomastoid structure, and balancing the temporal bones. However, larger prospective studies are needed in order to properly discuss the suggested efficacy on osteopathic manipulative medicine in the treatment of recurrent AOM or OME [15,16].
Manipulative therapy for the treatment of OM is performed in other countries around the world as well. In Europe, only in England, Belgium, Sweden, Switzerland, Denmark, and Norway chiropractors are recognized as primary health care providers. However, there is very little research done on the application of manual therapy in the treatment of OM in these countries. A 2006 survey of the chiropractors in the UK with regards to their scope of practice and effective treatment in various conditions showed that over 50% of chiropractors either agreed or agreed strongly that OM could be effectively treated by chiropractors. However, the same report suggests that more research is needed with regards to the chiropractic treatment of OM in children. There is no regulatory authority for the osteopaths in Europe and practice is performed on a country-by-country basis. However, in Switzerland and Austria osteopaths are recognized as Doctors and therefore, can treat patients based on their own clinical judgments. Chiropractic treatment of OM is also performed in Australia, where treatment of nonsuppurative OM is within the scope of their practice as outlined in the chiropractic association of Australia (CAA). Furthermore, osteopaths are recognized as primary health care providers as well in Australia and can make independent judgment in the treatment of their patients. In Iran, the chiropractic profession is well regulated within the health care community and chiropractors are well recognized as primary health care providers and manipulative treatments of OM are performed as a primary prevention routinely. However, as mentioned above, the research in this field is very limited and there are no unified guidelines among chiropractors or osteopaths globally with respect to treatments of conditions such as OM  [17].
Considering the fact that research indicates observation as an appropriate protocol for uncomplicated OM, it could be justifiable to avoid the usage of antibiotics and to proceed with manipulative and more conservative treatments in the management of OM. Chiropractic care could be an important bridge between the pediatricians and chiropractors in the management of children with OM. However, more research is needed to demonstrate the effectiveness of manual therapy in the management of OM  [1,7,9,11,14].
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4) Fallon J.M. The Role of the chiropractic adjustment in the care and treatment of 332 children with Otits Media. JCCP, 1997 Jan.          Vol.2;167-170.
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8) Clinical Practice Guidelines for diagnosis and management of Acute Otitis Media; American Academy of Pediatrics (AAP) and              American Academy of Family Physicians (AAFP); 2004.  aappolicy.aappublications.org
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12) Del M, Glaziou P, Hayern M, Are antibiotics indicated as initial treatment for children with  acute otitis media? A meta-analysis.          British Medical Journal 1997;314(7093)1526-1529.
13) Paradise JL, Feldman HM, Campbell TF, et al. Effect of early or delayed insertion of tympanostomy tubes for persistent otitis              media on development outcomes at ages of three years. New England Journal of Medicine: 2001;344(16):1179-1187.
14) Spiro DM, Tay R, Arnold DH, et al. Wait-and-see prescription for the treatment of acute otitis media: a randomized controlled            trial. Journal of the American Medical Association 2006;269(10):1235-1241.
15) Chila AG, Foundations of Osteopathic Medicine. 3rd ed. Baltimore: Lippincott Williams & Wilkins; 2011.
16) Carreiro JE, An Osteopathic approach to children. 2nd ed. Toronto: Churchill Livingstone; 2009.
17) Pollentier A, Langworthy JM, The Scope of Chiropractic Practice: A Survey of Chiropractors in the UK. Clinical Chiropractic, Sep.          2007;10(3):147-155.