A NOVEL APPROACH TO A “STICKY” OLD PROBLEM
One of the most difficult things to treat successfully in primary care practice is serous otitis media (SOM) or otitis media with effusion (OME), sometimes referred to as “glue ear”. Patients with SOM or OME complain of ear fullness or pain, popping or clicking, or some degree of hearing loss in their ear often accompanied by sinus and nasal symptoms.
Case 1: 4 year old boy with 4thURI in 2 months, tugging at both ears. On exam; tympanic membranes (TM’s) slightly pink yellow and bulging, slightly more on one side with visible small bubbles. Nasal discharge clear to yellow, mucosa pale distally, red proximally, posterior oropharynx is cobblestoned from drip. Conjunctiva slightly hyperemic, clear crusts in inner canthus. Nodes shoddy, non-tender.
DX: URI with post-nasal drip; possible allergic component; serous otitis media (SOM).
Standard guidelines: Conservative management with saline spray and humidifier. (1)
Typical Outcome: Mom calls after 5 days reports increased ear pain, fever and requests antibiotics. At PE 3 weeks later, still visible effusion in ear.
Case 2: 51 year old presents with 24 hours of sinus and ear pain saying, “I have a sinus infection. I always need antibiotics when it gets like this, I know my body.” On exam; nares slightly hyperemic with some clear discharge. TMs dull, off white to slightly yellow, one bulging, one retracted. Maxillary and frontal sinus regions tender to percussion.
DX: URI – Sinusitis – OME
Standard guideline : decongestants, antihistamines, often antibiotics are used. (2)
Typical Outcome: Patient returns in 10 days requesting extension of antibiotic or new antibiotic for unresolved symptoms.
THE BIRTH OF A NOVEL APPROACH
After years of working in family practice, I realized that when it came to serous otitis media, we do a lousy job. Despite evidence based research proving our standard approaches fail, we continue to provide pointless remedies. (3)
Like many working moms, I get URI’s frequently and fortuitously developed intense ear pain consistent with SOM one morning while driving to work. Knowing how long it takes to resolve, I responded with an audible, “Oh no!” and fervently massaged a tender trigger point above my ear, posterior to the temple, then attempted to manually drain my ET. There was a weird sound in my ear, followed by a sense of draining and an unexpected full resolution of my ear symptoms. Since then I’ve developed a successful effusion management strategy that is a blend of careful assessment, trigger point massage, osteopathic manipulations AND appropriate prescription /OTC medications.
CONCEPTUAL BASIS OF THIS NOVEL APPROACH
There are two fundamental problems that contribute to the formation of SOM/effusion and poor sinus drainage; abnormal mucus productionand structural impediments to drainage.
ABNORMAL MUCUS PRODUCTION
Mucus secreted in the mucus membranes maintains the integrity of the tissues and provides protection against viral and bacterial invasion. Excess mucus production is beneficial when it transports unwanted substances from the tracts. Unnecessary or thickened mucus improperly cleared leads to clogged nasal passages, sinuses and/or ETs.
With URI, this mucus is clear to cloudy, white to yellow and beneficial if properly cleared from the sinuses. In allergies, there is a over production of thin watery, clear to yellow fluid which initially helps in clearing the irritant, but ultimately is an excessive inflammatory response without benefit. There is occasionally non-beneficial clear fluid with sinus migraines, often mistaken as sinusitis. In “dry nose syndrome”; common in cold-dry climates, with oxygen use or with exposure to smoke; the cloudy mucus discharge is thick and either sparse, creating a sensation of fullness or excessive if the membranes have a reactive inflammatory response. Medicationscan dry mucus, increase mucus or actually cause URIs.
Patients with persistently blocked passages present with sore throats from mouth breathing, coughs from post-nasal drip, bronchitis from persistent coughing, effusions and eventually AOM, SOM, and bacterial sinusitis.
TREATMENT OF ABNORMAL MUCUS
It is critical to ask, “What is thesourceof the mucus?” before selecting the appropriate treatment (See Table 1).
TABLE 1: Treatment based on the source of the mucus
|Aggressive oral antihistamines –|
3rd gen. 24 hour daytime; 1st-2nd gen. night-time bolus
Saline to rinse out irritant
Nasal steroids -only in absence of URI or may cause infection
Nasal antihistamine sprays -can be used with URI
Frequent nose blowing using proper technique
|Dry Nose?||Nasal moisturizing gels –e.g. OTC Ponaris, AYR gel|
Rehydrate with Nasal Saline and increase fluid intake
|Migraine?||Saline rinse to clear mucus|
decongestants at onset if not hypertensive
|URI?||Frequent nose blowing using proper technique |
Saline lavage enhances elimination of bacteria
Guafenesin expectorants once mucus thickens
– under nose (over 2), throat, chest, esp.clavicles
(relaxes maxillary sinus),
– and on distal half of feet
(relaxes sinuses – great for pediatrics)
1st 2nd gen. antihistamines at night
– slows PND decreasing cough
-enhanced sleep supports immune system
Avoid decongestants which thicken mucus
-unless patient has structurally adequate and
patent sinus and drainage tracts
*Recognize that current efficacy studies of antihistamines, decongestants, and vicks have not been tested in conjunction withthe techniques described in this article.
STRUCTURAL IMPEDIMENTS TO DRAINAGE:
Skeletal Structure Impediments:
Adolescent and adult patients with the worst sinus problems tend to have thin noses, sunken eyes or a narrow skull design. At the same time, broad nose, large skull design patients (like a poker player with a cigar holding a bull dog) rarely have chronic sinus problems unless they have a mass. Sinus tracts are affected by the size and shape of the skull that forms them and subsequently this will impact on how well they drain, especially when there is an increase in mucus. The angle of the ET in infants is only 10⁰ which explains why they are prone to infections,4as mucus finds other outlets; coming out the eyes causing conjunctivitis or backing up into the ears.
Muscle Spasm Impediments:
My moment of “ah-ha” came when I was staring at that classic ENT “sinus cavities” anatomy picture and realized it was devoid of the muscles, ligaments and tendons over the sinus regions, around the nose, ear, and jaw and neck. Our standard guidelines reflect this picture, treating just the holes and tubes, missing the opportunity to treat the overlying muscles that impact their drainage!
To understand how much facial and head muscle tension impacts drainage, think of the last time you had a cold with sinus pain and you put your face under the hot shower, leaned your head back, relaxed and feeling some pain relief said, “Ahh.” After the shower, you cleared large amounts of mucus from your sinuses and gave full credit to the steam. However, even without the steam, if you are able to close your eyes, lean back and really allow your facial muscles to relax, you will find that you will also clear a large amount of mucus AND sense a decrease in sinus pain. Add a warm cloth or heating pad to your face and it will work even better. Add a muscle relaxer and you may clear the sinus blockage and pain within 24 hours.
The facial muscle tension can come from the URI itself. Sniffling results in the raising of the nose and creates a repetitive muscle strain in the central facial muscles. This leads to pain at the base of maxillary sinus and bridge of the nose where the muscles insert. Eventually nearby muscles tighten and lock up in a protective response gradually involving the whole face, ears and neck. Patients present with eyes squinted in pain with facial grimacing, shoulders slightly raised, looking as miserable as they feel.
Muscle tension can come from persistent frowning or teeth clenching associated with severe emotional stress, chronic anxiety or exposure to the cold. Neck and upper back muscles have proximal insertions that can tighten other muscles like a domino effect. Regardless of the origin of the muscle tension, it can block or alter the natural drainage pathways.
Self- Inflicted Impediments:
The classic impediment to drainage is the self defeating practice of sniffling usually seen in young children as each sniffle draws mucus backwards towards the ET. Alternatively, vigorous simultaneous blowing of both nares can damage the TM. Other habits such as chronic gum chewing, teeth grinding or gritting strains the TMJ muscles impairing drainage.
These require ENT intervention; e.g. deviated sinus, tonsil/adenoid issues, mass, abcess, cyst, and ET disorders . Recommend evaluation by a specialist if patient is not responding to treatment or presents with red flags such as atypical bleeding, persistent pain or hearing loss.
TWO STEP TREATMENT TO IMPROVE DRAINAGE
If the TM is bulging or retracted, palpate for tender or sensitive trigger points. The most common one is located above the ear, easily located by having the patient gently open and close their mouth while you palpate just posterior to the temple for the tender area along the moving muscle. Other common tender areas include the TMJ region and anywhere along the lateral base of the skull. Teach the patient to locate and gently massage these areas. It is important to focus on the TMJ region because it acts like the lock and key for all other facial and neck muscles. This area must be released first or the other muscles will not release properly. Relax the TMJ by having the patient slightly open and drop the mouth in a drool position then very gently massage the tender muscle.
After the trigger areas are relaxed, the ET can be “milked” externallyusing one finger starting behind the upper ear lobe tracing downward along the back of the ear in the crevice between the jaw and the neck.* Always “milk” downward using gentle but firm pressure. Even effusions without tender trigger points resolve faster if regularly milked.
It is vital for the patient to relax through the initial discomfort as the spasm is reduced with gentle massage. If the patient is unable to relax it will NOT work. Manipulation of a tensed muscle in spasm will irritate it. If the muscle is too sensitive to touch, have the patient ice the region intermittently and use NSAIDs before attempting the massage. If a patient has anxiety or situational stress, or if they have neck muscle tension, consider muscle relaxers to help unlock their facial tension. Patients with low pain tolerance or resistance to trying alternate therapies are not good candidates for this hands on approach.
*An alternative maneuver, developed by W.Galbreath D.O. in 1929 uses a mandible sweep technique. (4)
THIS NOVEL APPROACH – APPLIED IN PRACTICE
Revisit Case 1: 4 year old.
Chart review: Repeated antibiotics since birth, persistent effusion every exam despite ET tubes from 9 months through 3 years. SH: 2 cats, one dog – Mom insists animals aren’t problem since antihistamines and steroid sprays didn’t work. Objective: Sniffles loudly and deeply, refusing to blow his nose. Clear thick mucus. Shyly raises his right shoulder in a high shrug when spoken to. Eyes deeply recessed, nose petite, with small maxillary sinus cavity.
Analysis: Likely allergic or non-allergic irritant response to animal dander complicated by impaired drainage from structurally small sinuses, neck/shoulder muscle tension from mild anxiety, and sniffling without proper blowing.
Treatment: Decrease animal dander exposure, especially in the bedroom, saline spray BID, increase fluids, locate and massage triggers around ear and neck then milk the ET several times a day, use vicks on feet at HS, train in proper nose blowing, then retrial antihistamines and steroids with other modalities. The persistent obstinence of a non-nose blowing child can be frustrating to parents. Challenge the child to an outside game of “silly shooting” at rocks using one nostril at a time to get over the fear of blowing.
Outcome: Normal TM at two week follow up and he proudly demonstrates blowing his nose.
Revisit Case 2: 51 year old.
Chart review: seasonal symptoms, chronic ear/sinus problems with multiple antibiotics courses each “infection”. SH: recent death of her mother, responsible for aging father, daughter going through a messy divorce. Objective: Thin nose, furrowed tight forehead and temple region, jaw held is held in grimace position. Tender triggers near TMJ and above both ears. All neck support muscles tight and tender; relax in response to gentle massage.
Analysis: Stress and self-induced muscle spasms of the neck and TMJ impacting sinus and ear drainage. Chronic excess mucus likely from allergies, though stress predisposes her to frequent acute viral infections.
Treatment: Teach her to relax her jaw, face, neck, shoulders, then locate all the trigger points for her, around ears, TMJ and neck/shoulders. Demonstrate how to“milk” the ET. In lieu of antibiotics, prescribe non drowsy muscle relaxers and nighttime antihistamines. If triggers are too sensitive to touch, use NSAID’s for 1-2 days before beginning those manipulations.
Outcome: Resolution of her symptoms within 3 days. At next PE visit she shares she uses the muscle relaxer and starts the massaging anytime she feels the sinus and ear pain beginning and has not needed antibiotics in a year.
ROLE IN PRIMARY CARE
One of my patients, a women in her 30’s who had multiple sets of tubes and chronic ear problems all her life called back 48 hours later to report that for the first time in her life, she was able to clear her ears without antibiotics. I have dozens of families with young children whose persistent ear infections have been controlled with these interventions. Parents of infants and young children are especially responsive to learning these non-invasive techniques that may reduce the need for ear tubes. Expect to see a dramatic reduction in post-infection effusion, unresolved SOM cases and primary prevention of SOM in patients with mild effusion at presentation with URI by using this novel multi-disciplinary approach to treatment.
Patients with persistent SOM often return to their primary care provider after being “cleared” by ENT. Take a fresh look at the entire situation and find that missing piece of the puzzle; allergies, stress, repetitive muscle strain, personal behaviors, nervous habits, lack of sleep, airway irritants, secondary illness impairing immune system, or a medication causing URI symptoms. Chronic SOM cases require a careful analysis to identify and eliminate all the contributing factors in order to achieve successful resolution.
Teaching a patient about how relaxation of the TMJ, neck and upper back can improve chronic sinus and ear symptoms can have real impact on their quality of life. This is family practice at it best; treating the whole patient– their emotions, environment, muscles, ears and sinus tracts as one. These techniques work but you need to be forewarned that these formally quickie five minute URI visits will take longer to complete with the additional assessment and education.
Don’t get discouraged when some patients expect and demand antibiotics. Some patients are very resistant to acknowledge they are the source of their own pain. In these cases, offer the “traditional” treatment they came expecting so they can leave the office a happy and satisfied customer, then encourage them to follow up with their primary!
- American Academy of Pediatrics Clinical Practice Guidelines. Otitis Media with Effusion. Pediatrics. 2004; Vol. 113:5.
- Neff, Matthew. AAP, AAFP Release Guidelines on Diagnosis and Management of Acute Otitis Media. American Academy of Family Physicians. 2004; Vol.69:11, June.
- Williamson, Ian. Otits Media with Effusion in Children. Clinicalevidence.bmj.com. Web post date 2007; August.
- Pratt-Harrington, Dale . Galbreath technique: a manipulative treatment for otitis media revisited. JAOA. 2000; 10:635-639.
Unpublished article; Dr. Karen Smith DNP, FNP, 2019