Download Levator veli palatini

OMM 14- Sinusitis and Otitis Media
Anatomy
 Eustachian tubes empty out into the posterior-oropharynx. Several muscles attach to the eustachian tube and
play a role in opening the tubes orifice.
 In newborns the eustachian tube has a more horizontal approach. It isn’t until approximately 6 years of age that
the tube takes on a more vertical or anterior-inferior or declined orientation.
 Tube is closed / collapsed at rest
 Opens by action of tensor veli palatini and levator veli palatini (Muscles in nasopharynx)
Levator Veli Palatini
 Innervation: CN X
soft palate - functionally helps to seal nasopharynx from oropharynx
 Function: opens orifice of eustacian tube
Tensor Veli Palatini
 Innervation: branches of the trigeminal nerve
 Function: tenses the soft palate, which opens the eustachian tube
Parasympathetics
 OA
 AA
 Sphenopalantine Ganglion
Parasympathetic to nasopharyngeal mucosa travel by way of the Facial n. They synapse in the Sphenopalantine
ganglion
Sympathetics
 Physiologic effects
◦ Vasoconstriction leading to
 Reduced lymphatico-venous drainage
 Reduced nutrient supply to the tissues
 Dryness
 “cracking” of mucosal lining
◦ Increased goblet cells with continued sympathetic activity
 Thick, sticky respiratory secretions
◦ Pt is left with thick, sticky secretions and reduced capacity to drain sinuses and reduced capacity to
repair damage.
OMM 14- Sinusitis and Otitis Media
Chapman’s Points
 Anterior
› Sinusitis : First ICS along superior margin of rib 2 mid-line b/w mid-clavicular line and sternum
› Middle ear: Superior aspect of clavicle, about 1-2 cm from SC junction.
 Posterior
› Sinusitis
Nasal: lateral mass of C1
Sinuses: C2 just lateral of spinous process
› Middle ear: C1, postero-lateral aspect
Development of Sinusitis
 Maxillary and Ethmoid sinuses are present at birth.
 Frontal sinuses develop by around age 5 or 6.
 Sphenoid sinuses develop around age 8 to 10.
Function
 Provide fluidity and mucus to upper airways
 Vehicle for protecting against various organisms.
 Lessen weight of skull
What are the symptoms of sinusitis vs cold vs allergies
OMM 14- Sinusitis and Otitis Media
Sinusitis
Nasal congestion
Purulent rhinorrhea
Headache
Facial pain
Anosmia
Cough, fever
Tooth pain
Rhinitis
Nasal congestion
Rhinorrhea clear
Runny nose
Itching, red eyes
Nasal crease
Seasonal symptoms
Rhinitis: allergic stimuli
Pollen- weeds, trees, grass
Dust mites
Animal dander- dog, cat, others
Molds
Allergic foods and beverages
Rhinitis: non-allergic stimuli
Tobacco smoke
Perfumes
Cleaning solutions
Potpourri
Burning candles
Cosmetics, Hair spray
Car exhaust, diesel fumes
Changes in barometric pressure
Auto exhaust, Gas, diesel fuel
Causes of Mechanical Obstruction
• Deviated nasal septum
• Foreign body
• Nasal polyps
• Congenital atresia
• Lymphoid hyperplasia
• Nasal structural changes found in Downs syndrome
Predisposing Conditions
• Physical trauma
• Scuba diving
• Foreign body
• Cleft palate
• Dental disorders
• Any patient with chronic fatigue, fever, general malaise/aching or headaches should be evaluated for
sinusitis
OMM 14- Sinusitis and Otitis Media
Treatment of Acute Sinusitis
 Antihistamines recommended if allergy present.
o Loratadine
o Cetirizine
o Fexofenadine
 Decongestants
o Topical nasal sprays (limit use to 3 days)
Phenylephrine
Pseudoephedrine
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Antibiotic when indicated (bacteria)
-- Amoxicillin 500 mg tid for 10-14 days or 875mg bid
– First line choice in most areas
– Local differences in antibiotic resistance occur.
– Amoxicillin/clavulanate
– Cefprozil
Cefpodoxime
If penicillin-allergic patients- Clarithromycin or Azithromycin are available.
Erythromycin does not provide adequate coverage.
Trimethoprim/sulfamethoxazole has significant pneumococcal resistance.
Levofloxacin is an option in resistant infections.
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Nasal irrigation
Guaifenesin
Hydration
Organisms causing sinusitis and otitis media
• Streptococcus pneumoniae 40%
• Haemophilus influenza
25%
• Moraxella catarrhalis
25%
Numerous others totaling 10%
Staph aureus, coagulase-negative staph, anaerobic bacteria, others
Quality-of-Life Issues
• Fatigue
• Concentration
• Nuisance
• Sleep disturbance
• Emotional well being
• Social interactions
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Missing school/work
Halitosis
Decreased production
Impaired studying
Sniffing/snorting
Blowing nose
OMM 14- Sinusitis and Otitis Media
Sinusitis Complications
 Osteomyelitis
 Facial cellulitis
 Fistula
 Orbital cellulitis or abscess
 Cavernous sinus thrombosis
 Septic thrombophlebitis
 Meningitis
 Epidural, subdural, or intracerebral abscess
Radiology
 Sinus x-rays- they aren’t very sensitive or specific.
 CT scan- Study of choice. They should be performed in patients that you are considering for surgery, in patients
that aren’t responding to treatment, and in patients that worrisome findings are considered.
OMT for Sinusitis
 Suboccipital inhibition
 Cervical chain drainage
 Facial effleurage
 In-depth discussion in lab.
OMM 14- Sinusitis and Otitis Media
Otitis Media
 Inflammatory reaction to foreign antigens in the middle ear that cannot adequately drain via the eustachian
tube.
Epidemiology
 Roughly 1 ½ occurrences per year in average child.
 2nd hand smoke and daycare increase risk 3-5 times.
 Age < 2 years is most common. Older than 5 years of age occurrences should decrease.
 Usually less often in summer.
 Males > females
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Color appearance- Erythematous or yellow
Bulging tympanic membrane in acute illness
Often retracted in chronic infection
Some patients may have hearing deficit during time of infection
Decreased mobility with pneumatic otoscopy, especially in otitis media with effusion
Organisms
 Moraxella catarrhalis
 H. Influenzae
 Strep pneumoniae
Treatment
 Antihistamines and decongestants aren’t usually effective if the patient has a true infection.
 Amoxicillin- high dose in children
 Cefuroxime
 Cefdinir
 Ceftriaxone can be used in highly resistant patients
OMT Treatment
 Cervical chain drainage
 Auricular drainage technique
 Galbreath Technique
 In-depth discussion in lab.