Educational

Resolution of Ear Infection in a 4 Year Old Male: A Case Study Ashley McElroy, MS, DC

Abstract

Objective- The objective of this paper was to determine the efficacy of chiropractic care in the treatment of acute and chronic otitis media. As well as to determine the pathophysiology associated with such claims.

Clinical Features– The patient was a 4 year old male who presented with a history of acute ear pain, fever, lethargy, and previous diagnosis of acute otitis media.  The patient had a family history of severe otitis media that lead to the allopathic intervention of tympanostomy.

Intervention and Outcomes – The child was analyzed using motion palpation to identify areas of subluxation and adjusted using Diversified technique.  Within 12 hours of the specific chiropractic adjustment all related symptoms ( pain, lethargy, and fever) were completely resolved.  The patient has not had any form of otitis media since that time.

Conclusions – There is probable evidence leading to the conclusion that chiropractic care can affect the immune system is such a way that rapid resolution of acute and chronic otitis media is possible.

Key words: Subluxation, Diversified Technique, Otitis Media, Tympanostomy, Adjustment, Pediatric, tympanostomy, and myringotomy.
Introduction

There is a problem that plagues many parents rendering them in state of fear and concern for the child loved so dearly.  That condition is so common that I have yet to encounter a friend or family member that has never been afflicted with this prevalent childhood disorder.  What could be the cause of such trepidation?  The ear infection.  There are several categories and subcategories of ear infection with otitis media and otitis externa, more commonly known as Swimmer’s Ear, being the major headings.  Otitis media (OM) can be further broken down into 3 separate and distinct entities:

  1. Otitis Media with Effusion (OME)
  2. Chronic Suppurative Otitis Media
  3. Acute Otitis Media (AOM).

Otitis media with effusion is characterized by the persistence of effusion in the middle ear beyond three months without signs of acute infection. There is typically no pain, redness of the tympanic membrane, fever, or pus in the ear.  Chronic suppurative otitis media is characterized by continuing inflammation and otorrhea through a perforated tympanic membrane.  Finally AOM is diagnosed and characterized by an abrupt onset of local signs such as ear pain / pressure, inflamed tympanic membrane, and systemic signs such as malaise or fever.1 Children of preverbal age may show signs of distress by pulling the affected ear and demonstrating increased irritability.  Otitis externa is an infection of the ear and outer ear canal. It can cause the ear to itch or become red and swollen so that touching of or pressure on the ear is very painful. There may also be pus that drains from the ear.2

Epidemiology / Incidence/ Historical

Otitis media is the most common condition for which antibacterial agents are prescribed for children in the United States.3  It is also the leading cause of surgery in children in the United States.  By their third birthday, 80% of children will have experienced 1 or more episodes of OM, and more than 40% will have had 3 or more episodes. Reported otitis media ambulatory visits in US children younger than 2 years were 1244 visits per 1000 child-years in 2004, and 80% of those visits resulted in an antibiotic prescription. Otitis media also has a high socioeconomic impact worldwide. In the United States, an estimated $4 billion is spent yearly on OM-related health care.4

Acute otitis media can occur at any age, though it is most common between ages 3 months and 3 years old. At this age, the eustachian tube is structurally and functionally immature; the angle of the eustachian tube is more horizontal and the opening mechanism less efficient. This is because of the angle of the tensor veli palatini muscle and the cartilaginous eustachian tube.5

There are both viral and bacterial causes linked to the etiology of acute otitis media depending on the age of the patient.  In the neonate population the gram negative enteric bacilli E. Coli and Staphyloccus aureus are the leading causes of AOM.  In older infants and children < 14 years old, the most common causing organisms are Streptococcus pneumoniae, Moraxella catarrhalis, and Haemophilus influenzae.   In those over age 14 S. pneumoniae, group A β-hemolytic streptococci, and S. aureus are most commonly associated cause of AOM, followed by H. influenzae.5 Research shows that bilateral AOM seems to be a clinically only slightly more severe illness than unilateral AOM. Thus bilaterality should not be used as a determining criterion to determine the severity of the infection.6  Instead, the child’s symptomatic condition, organism of infection, and otoscopic signs should also be taken into consideration..  This is particularly significant as bacterial middle ear infection can spread locally, resulting in meningitis, subdural empyema, epidural abscess, lateral sinus thrombosis,  otitic hydrocephalus brain abscess, acute mastoiditis, petrositis, or labyrinthitis.5 This list of risks have historically lead to an antibiotic prescription rate in patients suffering from OM in the 80% range as recently as 1996.3  That rate has been steadily decreasing due to financial issues relating to insurance, such as copayments, that may limit doctor visits, public education campaigns regarding the viral nature of most infectious diseases, use of the PCV7 pneumococcal vaccine, and increased use of the influenza vaccine which will be addressed.3
Case Report

Patient History

The patient was a 4 year old child that presented on a Monday to CC-HOP with a personal medical history of allergies (cow’s milk, oak tree pollen, and grass) and a family medical history of chronic ear infection. Several of the patient’s paternal first cousins suffered from frequent severe ear infections that required tympanostomy surgery. During the surgical procedure, a small opening is made in the eardrum to place a tube inside. The tube relieves pressure in the ear and prevents repeated fluid buildup with the continuous venting of fresh air. In most cases, the membrane pushes the tube out after a couple of months and the hole in the eardrum closes. Although the treatment is effective, it has to be repeated in some 20 to 30 percent of cases. This surgery requires general anesthesia.7 The patients father has suffered with a unilateral ear infection every 3-4 years since childhood. The patient was born prematurely at 32 weeks of gestation via cesarean section.  The premature delivery was the result of pre-eclampsia and overly invasive medical intervention. The child was breastfed with formula supplementation for the first 3 months after birth. After the 3 month mark he was fed exclusively with formula.  He was diagnosed with acute otitis media at 1 year old and at 3 years old.  Each bout of the infection was treated with a course of antibiotics and pain/anti-inflammatory drugs. The symptomatic length of each infection lasted from 5-7 days.

At the patients 5th visit he had complaints of right ear pain that began 2 nights prior to his office visit.  The pain woke the child late Saturday night and prevented him from sleeping well that night and the following night.  The right ear was tender to touch at the time of the exam. The normally active and vibrant 4 year old was lethargic all day Sunday and Monday morning.  He refused food most of the day Sunday, only eating a small meal that night. The father stated that the child had a slight fever on Sunday but no analgesic or anti-inflammatory drugs were given to the child.

Patient Exam

The patient’s temperature was taken orally.  He had a fever of 99.9 degrees Fahrenheit.  The father stated that the child felt warmer than on Sunday afternoon.  An otoscopic exam was performed, showing an inflamed Tympanic Membrane with increased redness and bulging when compared to the unaffected left ear.  The patient was evaluated with Motion Palpation to determine the levels of fixation and to help localize possible subluxations.  The 8 point check was done to evaluate sacral extension and ilium flexion.  The 8 point check is performed by contacting the right upper joint at the posterior superior iliac spine ( PSIS) with the right thumb and the sacral vertebral level S2 with the left thumb.  The patient bent his right knee to 90 degrees while my thumbs remained on the right PSIS and S2.  I was looking for the PSIS to move posterior and inferior without the sacrum moving with it.  This test is performed bilaterally and the results are compared to each other.  If the test is performed while the contralateral leg is being raised to 90 degrees and posterior/ inferior movement does not occur it could indicate a relative sacral fixation.  While performing this test on the child the right ilium did not move posterior and inferior when compared to the left sides test results.  This indicated a right ilium fixation.  The listing for this fixation was further determined by performing a leg length analysis.  The patient was instructed to climb onto the adjusting table and line up the knees while they were bent into flexion.  This is done to assure the reliability of the leg length analysis.  Once to knees were correctly aligned parallel to each other the patient was allowed to lay prone on the table.  While the patient lay prone the legs lengths were visually compared to each other.  During this analysis it was determined that the right leg was shorter than the left leg by one fourth of an inch, indicating a right posterior inferior (PI) fixation and listing.  Palpation of the right PSIS also demonstrated edema located on the superior border of the PSIS, further supporting the diagnosis of right ilium PI.  The C1-C2 vertebral levels were evaluated with C1-C2 rotation.  My right index finger rested over the transverse process of C1 while my middle finger rested over the transverse process of C2.  My left hand contacted the top of the patient’s forehead and head.  Using my left hand I rotated the head towards the left, away from the contacts on the right, feeling for the transverse process of C1 to rotate anterior to the transverse process C2.  C1 on the right stopped rotating with C2, indicating the side of fixation.  The listing for that area of fixation was ASR.

Technique

The patient had been receiving Full Spine/ Diversified/ High Velocity, Low Amplitude (HVLA) adjustments at all previous visits. Once the listings of C1 ASR and R ilium PI were assessed it was determined that the patient would continue to receive this technique in order to correct the subluxations located.  The aforementioned technique(s) consist of specific contact manual thrust manipulations to the dysfunctional spinal motion units.8  The Diversified Technique is the classic chiropractic technique, developed by D.D. Palmer, DC. and taught in all chiropractic colleges. Diversified Technique was refined and developed by the late Otto Reinert, DC, to address biomechanical failure in each section of the spine, as it relates to specific subluxation. The focus is on restoration to normal biomechanical function, and correction of subluxations. Diversified adjusting of the spine uses specific lines of drives for all manual thrusts, allowing for specificity in correcting mechanical distortions of the spine. X-rays, motion palpation, and case histories are used in analysis and diagnosis. No instruments are used in this adjusting procedure.9

In order to correct this patient’s right PI listing the patient was adjusted with an Ilium push.  He was placed in the left side lying position while I contacted the inferior right PSIS with my left pisiform.  The specific line of correction was posterior to anterior and inferior to superior through the plane of the sacroiliac joint.  To correct the patients C1 ASR the patient was placed in the supine position and adjusted with the atlas supine cervical set.  I laterally flexed the neck to the right toward the right C1 contact, while rotating the nose away from the contact to the end of passive range of motion.  The contact was the C1 transverse process with the lateral portion of my right index finger.  The specific line of correction used to correct this misalignment was lateral to medial, superior to inferior, and posterior to anterior.

Hard and Soft Outcomes

The patient was motioned once again following the administration of specific chiropractic adjustments.  The 8 point check as well as C1-C2 rotation were performed immediately after the adjustments were delivered.  The motion palpation procedures were performed exactly as described previously in this paper.  Upon motioning of the previously fixated segments an increase in bilateral and symmetrical movement was felt.  The right ilium moved posterior and inferior in the same range of motion as the left ilium. While the patient lay prone the leg length was post checked.  They were perfectly balanced and symmetrical. There was also a significant increase in the movement of C1 following the adjustment. There appeared to be less resistance given by the patient during the post check.

I recommend water and rest for the patient and he was sent home.  The child slept through the night and woke up requesting breakfast. His fever was gone; his temperature was measured at 97.7.   There was no tenderness in the patient’s ear and he was back to his happy energetic self. Upon follow up otoscopic exam of the right ear there was no significant color irregularity or bulging. X-rays were never taken of this patient and instrumentation was not performed at that visits coinciding with the ear complaints.  At the initial visit instrumentation was done with the following results:

Moderate readings at T6-T7, T11, L2-3

Severe readings at T8-10, T12, L1, L5.

At the first reassessment the instrumentation readings were found to be mild or normal in the thoracic and lumbar regions.  This patient has not had any complaints of ear pain or possible ear infection since the treatment at that time.  The patient remained under remained under regular chiropractic care for the next year.  Care was discontinued December 2014.

 

Discussion

Review of Chiropractic Literature and Management

There are many proponents of chiropractic care that suggest that the removal of spinal subluxation can aid in the relief of otitis media. Otitis media is one of the most common causes of hearing loss among young children and the most common reason for emergency room visits in children in 1990.10  There are  many case studies, some literature reviews, and a RTC.  During my search for information to support my views I utilized the Index of Chiropractic Literature and Google Scholar.  With the search criteria of  “chiropractic” and “otitis media” I got 45 results in Index of Chiropractic Literature and 1,240 results in google scholar.  I used the limiting criteria of access to free full text, sources that are considered peer reviewed, the use of chiropractic care as the primary intervention, and the removal of any articles that I deemed to lack value in this discussion. This left me with 13 articles. See table 1 for a detailed breakdown of each article.

The final articles used to represent chiropractic literature and management were 9 case studies and 4 reviews of literature.  The case studies focused on patients suffering from otitis media that ranged in age from 16 months old to 9 ½ years old.  Six of the patients were female while the remaining 3 patients were male.   In addition to common diagnosis of a form of otitis media 3 of the patients also had measurable hearing loss associated with the infection.  There were even instances where the hearing loss was so significant it lead developmental language delays. In the case study by Pilsner et. al. a four year old male was diagnosed with expressive speech delay, developmental delay, and behavioral issues associated with his recurrent ear infections. After treatment his behavior improved, auditory tests showed his hearing to be within normal range and progress was made with his speech.10  In the case presented by Brown a 3 year old girl who stopped responding to auditory stimuli as well as beginning to pronounce “f’s” in front of each word. After 7 visits she began to be more attentive and the child made the statement that she could “hear again.”11 The 3rd case of OM associated hearing loss was presented by Dwyer and Boysen.12  They treated a 6 year old male that was subjected to the allopathic treatments of antibiotics and myringotomy which were only minimally effective. Interestingly the use of antibiotics is associated with development of Asthma, a chronic and often lifelong ailment, by the age 7.13 After chiropractic care the hearing issues resolved and there was no recurrence of symptoms or infection. Each of these patients was cared for with 5 different techniques: Diversified Technique(6), Activator Technique (5), Gonstead, Applied Kinesiology, and CBP. The majority of these cases used multiple techniques to achieve successful results in addition to ancillary treatments such as soft tissue effleurage of the SCM, trigger point therapy, and cervical traction (2).  Only O’Connor, Cuthbert, Marino, and Lanjopoulos used a single technique in the treatment of these patients. 14,15,16,17   The majority of patients received Diversified technique at some point in the treatment time frame.  I too used Diversified in the care of my patient.  As stated previously this technique is taught at all chiropractic schools and was created by D.D. Palmer and refined by Reinert.  It is the most widely used technique in North America.9  It is also of importance to note that the insertion / reinsertion of tympanostomy and myringotomy  tubes was prevented at least in part by the introduction of chiropractic care.11,13,14,18  The review of literature assessed during the research process showed inconclusive results.  They all came to the conclusion that there was limited quality evidence to either support or refute the use of chiropractic care for the treatment of any form of otitis media.1,19,20,21

 Review of Allopathic Management

As per the Agency for Healthcare Research and Quality acute otitis media is a viral or bacterial infection of the middle ear and represents the most common childhood infection for which antibiotics are prescribed in the United States (US).22 It has been estimated that the annual medical expenditures for treating OM in US children (including AOM and OM with effusion) to be approximately $2 billion.22  Surprisingly with such a large amount of medical care being expended to treat these conditions there are only 4 major courses of treatment used.  Those treatments include:

1)analgesics for the reduction of otalgia,

2)antibiotic therapy to resolve the infection

3) observation for spontaneous resolution

4)surgery for recurrent cases of  AOM.

The treatment of otalgia achieved primarily via the use of analgesics.  Pain is relieved after the administration of antibiotics, due to the eventual decrease in eustachian tube pressure, but the reduction of pain does not occur in the first 24 hours.  Analgesic use on the other hand will began to relieve pain during that initial 24 hour mark.  According to the Merck Manual all patients should be given an analgesic such as acetaminophen and ibuprofen.5

Antibiotic therapy has been the first line of treatment for AOM and chronic otitis media (COM) for years.  Though 80% of cases resolve spontaneously antibiotics are given in 76% of cases.3,5  This over utilization of antibiotics may have contributed to the recent emergence of resistant organisms. Risk factors for resistant pathogens include recent antibiotic treatment of acute otitis media, children in daycare facilities, wintertime infections and acute otitis media in children less than two years of age.23  It is recommended the medical professionals only prescribe antibiotics for those most in need.  If the AOM diagnosis is certain all children under 2 receive a course. Children over 2 with a certain AOM diagnosis should only receive antibiotics if the case is severe.  In cases where the AOM diagnosis is uncertain all children under 6 months receive a course while those >6 months only receive a course of antibiotics if the case is severe.5  Despite significant publicity and awareness of the 2004 AOM guideline, evidence shows that clinicians are hesitant to follow the guideline recommendations, continuing to prescribe antibiotics at higher rates.3  The antibiotics of choice are Amoxicillin, although a higher dosage (80 mg per kg per day) may be indicated to ensure eradication of resistant Streptococcus pneumoniae. Oral cefuroxime or amoxicillin-clavulanate and intramuscular ceftriaxone are suggested second-line choices for treatment failure.23

In children > 2 years old with mild confirmed cases of AOM as well as those > 6 months old with mild uncertain AOM diagnosis it is recommended that the patient be observed for 72 hours before antibiotic regimen is started.5  This route of providing care has been shown to not increase suppurative complications, provided that follow-up is ensured and a rescue antibiotic is given for persistent or worsening symptoms.  The use of a rescue antibiotic if needed is an integral part of the observation process. This is often done by using a “safety net” or a “wait-and-see prescription in which the parent/caregiver is given an antibiotic prescription during the clinical encounter but is instructed to fill the prescription only if the child fails to improve within 2 to 3 days or if symptoms worsen at any time.3

The final and most invasive form of treatment includes the use of surgery, tympanostomy, to defend against the threats OM may present.  During the surgical procedure, a small opening is made in the eardrum to place a tube inside. The tube relieves pressure in the ear and prevents repeated fluid buildup with the continuous venting of fresh air. In most cases, the membrane pushes the tube out after a couple of months and the hole in the eardrum closes. The treatment has to be repeated in some 20 to 30 percent of cases.7  Most of the studies published about the efficacy of tympanostomy tubes for treatment of ear disease focus on those children with persistent middle ear effusion.  Studies regarding its use in AOM is scant.  Despite the lack of supporting research there is conflicting data on the perception and use of this intervention for AOM. In a survey of Canadian otolaryngologists 40% reported they would “never,” 30% reported they would “sometimes,” and 30% reported they would “often or always” place tympanostomy tubes for a hypothetical 2-year-old child with frequent OM without persistent MEE or hearing loss.3

There is a shortage of research that focuses on prevention though there is mention of increased utilization and development of more vaccines for the pathogens that commonly lead to this infection. Routine childhood vaccination against pneumococci (with pneumococcal conjugate vaccine), H. influenzae type B, and influenza decreases the incidence of AOM according to the Merck Manuals. 5   There are no allopathic recommendations for the use CAM care for the prevention or treatment of any form of OM.

Proposed Mechanism

The mechanism I believe contributes significantly to the positive effect of chiropractic care in the treatment of otitis media is the concept that chiropractic care improves immune function in its recipients. There are several articles that show how chiropractic care has a positive effect on visceral conditions, immunity, and an improved feeling of wellness among other things.

The patients and families of the studies by Leboeuf, Wittman, Boone, and Alcantara reported a number of subjective findings related to chiropractic care and the topic at hand.24,25,26,27  There were reports of improved breathing, digestion, and circulation in 3-27% of the participants in the Leboeuf study.  The participants of Boone’s research demonstrated a significant increase in their “Life Enjoyment.”  The values rose from .57 to .65 (p=0.026).   The parents of children in these studies reported that their children felt less irritable, episodes of illness were much easier on their children, and that the recurring issues resolved much faster whilst under chiropractic care.  The reported positive subjective findings in pediatric patients could be the psychological branch of immunity as demonstrated by the Psycho-Neuro-Endocrine Immunity concept.

The concept of Psycho-Neuro-Endocrine Immunity is presented in Figures 1 and 2.  According to this system of biological interactions there is constant communication between the nervous, endocrine, and immune systems via the messengers produced by each. Changes to one system modifies the others and vice versa.  As demonstrated in Figures 1 and 2 internal forces directly affect the nervous system and it in turn has a direct effect on the immune system.  The subjective findings presented by the aforementioned articles can play a major role in this system.  One must first understand the role emotions have on health.  When patients believe and feel that they are improving, it has a direct impact on how the immune system functions. The emotional standing of the patient has a role in dictating how well the immune system will respond to injury, infection, and foreign invaders. Many of the case studies focusing on otitis media make note that the chiropractor tries to keep the office a pleasant place for their pediatric patients, thus improving their emotional state in relation to chiropractic care. When the subjective findings show that a patient feels like there has been a physical or mental improvement there is a physiological response that can be traced through the psyco-neuro-endocrine system.  A patient that feels positive about the care they receive can be considered a fighter.  Their mental status will trigger the Amygdaloid Central Nucleus. The amygdala receives neuronal signals from all portions of the limbic cortex, which when stimulated produces either positive emotions of pleasure/satisfaction or negative emotions of terror, pain, or fear.  The amygdala then stimulates the hypothalamus.  The hypothalamus stimulates the sympathetic nervous system via nerve fibers  that project to  areas of the sympathetic motor system (lateral horn spinal segments T1-L2/L3)  and are carried by the hypothalamospinal tract to the adrenal medulla.28  Stimulation of the adrenal medulla causes the release norepinephrine which has the effect of stimulating the immune system.28 Norepinephrine binds to β2-adrenoreceptors on antigen-presenting cells and helper T cells, thereby inhibiting the production of TH1, proinflammatory cytokines, while stimulating the production of TH2, anti-inflammatory cytokines.  This protects the body from production of proinflammatory cytokines and other products of activated macrophages.29

Objective increases in immunity factors were mentioned in the articles by Basso, Boone, Teodorczyk, and Shor-Posner.30,31,32,33  The study produced by Basso showed an increase in the complete white blood cell count of a 16 year old diagnosed with juvenile idiopathic arthritis.  Among this patient’s symptoms was a decreased WBC count that subsequently increased after chiropractic care.  There was a suggested link between the increased levels of physical stress and the decreased CD56 counts.31 One can thus conclude that removal of the physical stress, like an atlas fixation, can lead to an increase in CD56 counts.  Levels of IgG and IgM were shown to be significantly elevated (F=2.3, P=.03, F=2.68, P=.04) in patients that received spinal manipulation with cavitation.32

The objective findings of increased IgG/IgM, complete WBC, and the potential to increase CD56 are significant findings in the realm of immunity. There are several classes of antibodies and the roles of IgG and IgM are quite important.  IgG is of particular importance as it is a bivalent antibody that constitutes 75 percent of the antibodies found in a normal person.28  The IgM class is also interesting because they have 10 binding sites that make them very effective during an immune response. They make up a large share of the antibodies formed during the primary response, yet there are not many of them. In general antibodies protect the body by directly attacking invaders (lysis, agglutination, etc.) and by activation of the complement system that will destroy invaders in a cascade of reactions that ends in the lysis of cells. The CD56 cells fall into the immune category of Helper T Cells.  Helper T cells are the most numerous of the T cells, making up more than 3 quarters of all of them.  They help in the functions of the immune system in many ways, especially regulation of most immunity.  This regulation is done by the production of protein mediators called lymphokines that act on other cells of the immune system.  Chiropractic care can play an important role in the improvement and responsiveness of the immune system.  These changes can be attributed to the rapid resolution of the symptoms of my patient.

Limitations

Otitis Media Focus-Chiropractic

There were many strengths to the studies reviewed.  They were all very through in the explanation of the care provided and the presentation of the patients.  I feel that the methods used in each case study could be reproduced in the office on Monday morning.  Despite these strengths there are major limitations that present when searching for and reviewing the chiropractic treatment of the different forms of Otitis Media.  The first problem that arises is the lack of randomized control studies.  This is the norm with chiropractic research, but I feel that it is a significant issue in this case.  There are children suffering from middle ear infections that are subjected to antibiotic treatments and in the worst case surgeries that require anesthesia. Antibiotics are only effective when the infection is caused by bacteria, over prescribed, and their use has been linked to the development of Asthma.  The tympanostomy tube surgery is effective, but has to be repeated in up to 30 percent of patients.  If our profession could provide more high quality research those outcomes could be avoided. The next limitation I encountered with the chiropractic otitis media focused research was that the research that was done had very small populations.  Every article that met my search criteria dealt with one child per case study and there were only a handful of those.  Finally adverse effects to care were not addressed at all in any of the studies.  I am sure that adverse reactions to care were not listed because there were known, but the allopathic world cannot accept this concept (because that is never the case in their research).  If there were no adverse reactions to care then it should have been mentioned at some point.  Finally there is an inherent limitation that was found in both the studies used for reference and the patient I cared for myself.  The limitation is the fact that 80% of ear infections resolve spontaneously without additional care.  I cannot be sure that it was my care alone that resolved the case, just as the other chiropractic researchers are faced with the same dilemma.

Otitis Media Focus-Allopathic

The research that is done by the allopathic community is of high quality, but there doesn’t appear to be enough information regarding the use to tympanostomy in certain populations.

Immunity-Chiropractic

The strengths of the presented research include its thorough representation of immunity.  The majority of the articles did a great job of presenting the different aspects of the immune system. They all presented information that would get the reader up to speed about human immunity as a whole as well as the specific conditions being explored by the case study. The articles by Cohn, Cramer, and Teodorczyk did an exceptional job in producing the necessary information needed to understand how the immune system works.  Cohn explains that the body repairs damage, fights / prevents infection, and destroys cancerous cells. Per this article we are informed that the adaptive immune system works by tasking B cells, T cells, and antibodies to overwhelm invaders. We also learn information regarding neuromodulators and chemical messengers of the immune system.34  Cramer does a wonderful job explaining how the neuromodulators described in the Cohn article are shared by the nervous system.  It is through these shared neuromodulators ( cytokines and neurotransmitters like norepinephrine)  that  the  immune and nervous system can communicate and mediate basal / stress related homeostasis.29  Finally Tepdorczyk  explains how the anatomy of close autonomic nerve terminals to macrophages and lymphocytes facilitates the transmission between nerves and immune cells.  Though there is clear and thorough explanation of the connection between the immune system and the nervous system, the issue of addressing pathophysiologic connection between chiropractic treatment and improved immune function leaves something to be desired.

 

Conclusion

Recommendations

Children suffering from acute or chronic cases of otitis media are welcome in our offices.  Through the research I have reviewed in the development of this article and my practice experience I have come to the conclusion that the application of a specific chiropractic adjustment for the removal of subluxations is beneficial to the stimulation of the immune system.  This stimulation helps the body heal itself quickly and reduce the need for allopathic intervention that may be harmful to the child.  My case study showed a probable resolution to an AOM case that did not require the use of antibiotics, analgesics, or anti-inflammatory drugs.

Call for More Research

As with all topics related to chiropractic treatment additional quality research is needed.  There needs to be a systemic approach to reporting adverse effects.  The general practice and intervention protocols should be formulated so that they can be applied to a larger population. The validity of future research should be increased by the utilization of techniques such as tympanometry, otoscopy, and thermography. Comparison groups such as non- treatment versus chiropractic treatment should be studied in large trials that include at least 1000 children per study as well.  I suggest this future research be funded by both Life University and the ICPA and performed by ICPA doctors and graduates of Life University.

 

Acknowledgements

Thank you to Dr. Gwendolyn Gardner and Dr. Paula Rhodes for your time and assistance. I would also like to thank my Life University family for their continued support during the construction of this paper.

 

References

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8) Wood T, Colloca CJ, Matthews R. A pilot randomized clinical trial on the relative effect of instrumental (mfma) versus manual (hvla) manipulation in the treatment of cervical spine dysfunction. J Manipulative Physiol Ther. 2001 May; 24(4):15-23.

9) Leigh J. West Family Chiropractic [Internet]. Westford: Chiromatrix; 2013 [Cited 2015 March 1]. Available from: http://westfordchiropractic.com/chiropractic-treatment-techniques.html

10)Pilsner R, Richardson M. Improvements in hearing, speech, development, and behavior following chiropractic in a 4 year old male. J Pediatr Matern & Fam Health[Internet]. 2011[cited 2015 Feb 19];2011(1):14-22. Available: http://chiropracticpediatrics.sharepoint.com/Pages/2011_1037_otitis.aspx

11) Brown C. Improved hearing and resolution of otitis media with effusion following chiropractic care to reduce vertebral subluxation. J Pediatr Matern & Fam Health[Internet]. 2009 [cited 2015 Feb 19];2009(1):1-7. Available from: http://chiropracticpediatricresearch.web.officelive.com/2009_1004_otitis.aspx

12)  Dwyer PJ, Boysen J. Resolution of conductive hearing loss due to otitis media after chiropractic treatment. J Clin Chiropr Pediatr. 2011 Dec; 12(2):903-9.

13) Fedorchuk C, Cohen A. Resolution of chronic otitis media, neck pain, headaches & sinus infection in a child following an increase in cervical curvature & reduction of vertebral subluxation. J Pediatr Matern & Fam Health[Internet]. 2009 [cited 2015 Feb 19];2009(2):1-8. Available from: http://chiropracticpediatricresearch.web.officelive.com/2009_1009_otitis.aspx

14) O’Connor K, Schneider G, Alcantara J. Resolution of otitis media, improvement in hearing and avoidance of myringotomy tubes following chiropractic care in a child: A case report and selective review of literature [case report; review]. J Pediatr Matern & Fam Health[Internet].  2014 [cited 2015 Feb 19];2014(3):47-54. Available from: http://chiropracticpediatrics.sharepoint.com/Pages/2014_1327_otitismedia.aspx

15) Cuthbert SC, Rosner AL. Applied kinesiology management of candidiasis and chronic ear infections: A case history. J Pediatr Matern & Fam Health[Internet]. 2010 [cited 2015 Feb 19];2010(3):122-9.  Available from: http://chiropracticpediatricresearch.web.officelive.com/2010_1042_candidiasis.aspx

16) Marino Francesca M., Butt Awais. Chiropractic care of a pediatric patient suffering from recurrent otitis media and respiratory syncytial virus: a retrospective case report. J Pediatr Matern & Fam Health[Internet]. 2010[cited 2015 Feb 19];2010(4):183-5. Available from: http://chiropracticpediatrics.sharepoint.com/Pages/2010_1067_om_rsv.aspx

17) Lanjopulos C, Lanjopoulos D. Resolution of chronic otitis media, difficulty sleeping, and tactile hypersensitivity in a child undergoing subluxation-based chiropractic care. J Pediatr Matern & Fam Health[Internet]. 2012 [cited 2015 Feb 19];2012(3):81-4. Available from: http://chiropracticpediatrics.sharepoint.com/Pages/2012_1084_otitismedia.aspx

18) Stone-McCoy P, Korn C. Resolution of otitis media and avoidance of tympanostomy tubes in a 16-month old with birth trauma following subluxation based case: A case study and selective review of literature. J Pediatr Matern & Fam Health[Internet]. 2013 [cited 2015 Feb 19];2013(2):39-46. Available from: http://chiropracticpediatrics.sharepoint.com/Pages/2013_1264_otitis.aspx

19)Gleberzon B, Arts J, Mei A, McManus E. The use of spinal manipulative therapy forpediatric health conditions: a systematic review of the literature. J Can Chiropr Assoc. 2012; 56(2):128-144.

20) Pohlman KA, Holton-Brown MS. Otitis media and spinal manipulative therapy: a literature review. J Chiropr Med. 2012 Sep; 11(3):160-9.

21) Bronfort G, Haas M, Evans M, Leininger B, Triano J. Effectiveness of manual therapies: the UK evidence report. Chiropr & Osteopat. 2010; 18(3):1-33.

22) Shekelle PG, Takata G, Newberry SJ, et al. Management of acute otitis media: update. Rockville (MD): Agency for Healthcare Research and Quality (US); 2010 Nov. Available from: http://www.ncbi.nlm.nih.gov/books/NBK56132/

23) Pichichero ME. Acute otitis media: part II. Treatment in an era of increasing antibiotic resistance. Am Fam Physician. 2000 Apr 15; 61(8):2410-16.

24)Leboeuf-Yde C, Pedersen EN, Bryner P,  Cosman D, Hayek R, Meeker WC, et al. Self-reported nonmusculoskeletal responses to chiropractic intervention: a multination survey. J Manipulative Physiol Ther. Jun 2005; 28(5):294-302.

25)Wittman RA, Vallone SA. Inclusion of chiropractic care in multidisciplinary management of a child with prader-willi syndrome: a case report. J Manipulative Physiol Ther. 2009; 8(1):193-9.

26) Boone WR, Oswald P, Holt K, Beck R, Singh K, Ashton A. Physical, physiological, and immune status changes, coupled with self-perceptions of health and quality of life, in subjects receiving chiropractic care: a pilot study.  J Vert Sublux Res. 2006 Jul; 2006:1-6.

27) Alcantara J, Van Roo L, Oman R. Chiropractic care of a pediatric patient with asthma, allergies, chronic colds & vertebral subluxation. J Pediatr Matern & Fam Health. 2009 Aug; 2009(3):1-7.

28) Guyton AC, Hall JE. Textbook of medical physiology. 11th ed. Philadelphia: Elsevier; 2006.

29) Cramer G, Budgeli B, Henderson C, Khaisa P, Pickar J. Basic science research related to chiropractic spinal adjusting: the state, the art and recommendations revisited. J Manipulative Physiol Ther. Nov 2006; 29(9):726-761.

30)Basso E, Potrzebowski S. Resolution of juvenile idiopathic arthritis & improved immune function in a 16 year old undergoing chiropractic care: a case study. J Pediatr Matern & Fam Health. 2014 Oct; 2014(4):65-9.

31)Boone WR, Oswald P, Holt K, Beck R, Singh K, Ashton A. Physical, physiological, and immune status changes, coupled with self-perceptions of health and quality of life, in subjects receiving chiropractic care: a pilot study.  J Vert Sublux Res. 2006 Jul; 2006:1-6.

32)Teodorczyk-Injeyan JA, McGregor M, Ruegg R, Injeyan HS. Interleukin 2-regulated in vitro antibody production following a single spinal manipulative treatment in normal subjects. Chiropr & Osteopat. 2010; 18(26):1-8.

33)Shor-Posner G, Miguez MJ, Hernandez-Reif M, Perez-Then E, Fletcher M. Massage treatment in HIV-1 infected Dominican children: a preliminary report on the efficacy of massage therapy to preserve the immune system in children without antiretroviral medication. J Altern Complement Med. 2004; 10(6):1093-5.

34) Cohn A. Chiropractic and the neuroimmune connection. J Vert Sublux Res. Sep 2008; 2008:1-5.

 

Table 1: Index of Chiropractic Otitis Media Focused Articles

Author

CCP Rating

Category of Evidence

Study

Type

Participants Presentation Intervention Results
Gleberzon J

et. al.

Investigational /E

Review

of Literature

N/A N/A N/A Limited quality evidence to support Chirp care
Pohlman, K

et. al

Investigational /E

Review

of Literature

N/A N/A N/A Limited research to support or refute Chiropractic care
Bronfort, G

et. al

Investigational /E

Review

of Literature

N/A N/A N/A Inconclusive evidence regarding effectiveness
Feffance, R et. al

Investigational /E

Review

of Literature

N/A N/A N/A No credible evidence to make recommendations
Stone-Mccoy, P

Investigational /E

Case Study 16 month old male Recurrent Ear Infection Activator

Sustained contact

Sinus work

Soft Tissue

Resolved symptoms & avoided

tympanostomy

Brown, C

Investigational /E

Case Study 3 yr old girl Bilateral ear pain,

effusion, and hearing loss

Diversified

Activator

Cervical Distraction

 

Resolution of symptoms via audiology test
O’Connor, K

et. al.

Investigational /E

Case Study 9 ½ year old girl Chronic ear infection, Hearing loss, headache, neck pain Diversified

3x/week for 3 weeks

Total remission of chronic ear infection
Author

CCP Rating

Category of Evidence

Study

Type

Participants Presentation Intervention Results
Dwyer, P

et. al.

Investigational /E

Case Study 6 year old male OM and conductive hearing loss Gonstead

Diversified

Resolution of all symptoms, no recurrence
Cuthbert, S

Rosner, A

Investigational /E

Case Study 6 year old female Candidiasis

Recurrent Ear Infection

Applied Kinesiology Resolution of symptoms for the past 2 years
Fedorchuk, C

Cohen.A

Investigational /E

Case Study 8 year old female OM, cephalalgia, sinus infection Trigger points

Diversified

Mirror imagery

CBP

traction

Resolution of symptoms
Marino, F

Butt, A

Investigational /E

Case Study 21 month old female Recurrent, RSV Diversified

3x / week for 3 months

Resolution of OM after 1 month & RSV after 3 months
Pilsner, R

Richardson

Investigational /E

Case Study 4 year old male OM Effusion, adenoid hypertrophy, Bilateral hearing loss, decreased speech and development Instrument Adjustment

Diversified

Resolution of all symptoms
Lanjoponlos, C

Lanjoponlos, D

Investigational /E

Case Study 2 year old female Chronic OM, Sleep disturbance Activator After 3 visits improved sleep, 4 months ear infection resolution

 

 

Figure 1: The following diagram depicts the physiological inter-relational aspects of the Neuro-Immuno-Endocrine Triad and the common external factors that impact them.

 

 

 

is-1

 

 

Figure 2: The below diagram represents the Psycho-Neuro-Endocrine immune function.

is-2

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