Osteopathic Treatment For Patients With Sinusitis

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Osteopathic Treatment For Patients With Sinusitis
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3D frontal view
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47 Year old female with frontal headache and
yellow nasal discharge

• Fronto-occipital headache, face pain and sore
  throat x 4 days
• Unable to clear secretions when blowing nose
• Post nasal drip with minimally productive cough
• Gets 2-3 sinus infections/year

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PM/Surg/Soc/FamHX

• Occipital/Tension headaches
• GERD, usually controlled but symptomatic when has
  post nasal drip
• Irregular menses/perimenopausal
• Environmental allergies trigger sinusitis in
  spring and fall
• sinus surgery 2 yrs ago helped, but didnt
  resolve problems
• Nonsmoker, no pets
• Several siblings with chronic sinus problems

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Trauma/Birth History

• Onset occipital headaches when stood up into a
  4x6 board 12 years ago, hitting on the back of
  the head. Lost consciousness for a few minutes.
• Was a large baby, otherwise unknown

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Meds/Allergies

• Omeprazole, Loratidine, Multivitamin, Calcium D.
  
• Azithromycin, Guaifenesin, nasal steroids are the
  usual sinusitis regimen that resolves her
  symptoms
• NKDA

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Physical Exam

• VSS
• Afebrile
• NAD
• HEENT NC/AT, face symmetrical
• TM grey with good landmarks but left retracted.
  No effusion.

• Nasal mucosa swollen with yellow drainage from
  ostia L
• Pharynx injected, pebbled, without exudate or
  tonsillar enlargement
• Yellow post-nasal drip

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Physical Exam

• Tender to palpation frontal, nasal and left
  maxilla
• No cervical, supraclavicular or infraclavicular
  adenopathy
• Lungs CTAB
• Heart RRR without murmur
• Minimal epigastric tenderness, no mass/rebound
  tenderness/rigidity/guarding

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Structural Exam
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• Thoracic inlet sidebent right, rotated left
• First rib superior on the left
• Positive Left anterior subclavicular Chapmans
  reflexes
• Bilateral posterior upper cervical Chapmans
  reflexes
• C2 FRSR
• OA FSLRR

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Anterior Chapmans Reflex
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Posterior Chapmans Reflex
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More Structural Exam

• Decreased CRI
• Poor compliance/tender at left mastoid process
  and nasion
• Left maxilla internally rotated
• Left pterygopalatine fossa soft tissues boggy

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What else should be included?
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Impression/Plan
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Possible treatment sequence for this patient
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• Indirect or direct MFR to thoracic inlet and
  thoracoabdominal diaphragm if needed
• ME, FPR or BLT to left first rib
• Treat posterior cervical Chapmans reflexes.
• Check to see if anterior reflexes less tender.
  If not, treat them too.
• Treat upper cervicals with suboccipital release,
  ME, BLT or Still
• Sacral motion restriction may need to be
  addressed.

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Sympathetic Relationships in the Cervical Region
Superior cervical ganglion
Middle cervical ganglion
Inferior cervical ganglion
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Where would you start for this set of cranial
findings?
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• Decreased CRI
• Poor compliance/tender at left mastoid process
  and nasion
• Left maxilla internally rotated
• Left pterygopalatine fossa soft tissues boggy

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Possible sinusitis techniques

• Choose which apply to your site then delete the
  irrelevant slide(s)
• Venous sinus drainage sequence (precede with OA
  release and end with frontal/parietal lifts)
• Fronto-zygomatic lift
• Alternating lateral rocking of the nasion
• Sphenopalatine ganglion release
• Percusssion/ jello tap over involved sinuses
• Effleurage over frontals, nasals, maxillae and
  towards mastoids
• Supra Infra orbital nerve stimulation

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Nasion, Supraorbital and Infraorbital Foramina
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Fronto-nasal Release

• Cephalad Hand contacts the frontal with two
  finger pads
• Caudad Hand contacts the two nasal bones with
  thumb and index
• Gently distract
• Can also be done for fronto-maxillary sutures.

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Supraorbital and Infraorbital Foramina

• Locate the foramen along the superior orbital
  ridge or the inferior orbit
• Gentle finger pad contact is used to massage the
  nerve and surrounding tissues
• A slow rotary motion back and forth is often
  quite effective.
• This can be easily taught to the patient for home
  use.

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Trigeminal Nerve, Sphenopalatine Ganglion
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Intimate relationship with the Maxillary Branch
of the Trigeminal N.
Sphenopalatine Ganglion

• Note Relative flatness of pterygoid process
  compared to rounded maxilla

Sutherland, Teachings in the Science of
Osteopathy, p. 96
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Sphenopalatine Ganglion

• Note that the spenopalatine ganglion is suspended
  from the maxillary nerve

Sutherland, Teachings in the Science of
Osteopathy, p. 96
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Treatment of the Sphenopalatine Ganglion

• Stand opposite the side to be treated
• Caudal Hand Introduce the little finger of the
  caudal hand softly carefully along the alveolar
  ridge past the tuberosity of the maxilla on to
  the lateral plate of the pterygoid it is a
  flatness in contrast to the curved maxilla
• The patient may have to move the ramus of the jaw
  laterally to create room for the finger

Craniosacrale Osteopathie II, p.99
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Treatment of the Sphenopalatine Ganglion

• Once in position have the patient tip the head
  against the pad of the little finger to
  tolerance, or
• apply gentle inhibitory pressure medially
  cranially in the direction of the outer orbit
• It can be quite painful
• Pressure on the ganglion will stimulate it to
  action which will be indicated by lacrimation
• Decreased tissue tension also indicates
  completion of this technique

Craniosacrale Osteopathie II, p.99
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References

• Grants Atlas Digital Images
• American Academy of Otolaryngology - Head and
  Neck Surgery One Prince StreetAlexandria, VA
  22314-3357
• http//www.entnet.org/healthinfo/sinus/sinus_side.
  cfm

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Treatment of the Sphenopalatine Ganglion

• Fluid-wave Technique
• Cranial Hands Thumb is on the coronal suture
  opposite the sphenopalatine ganglion contact at
  the longest diameter
• Gentle pressure is directed toward the ganglion
  in coordination with the cranial impulse

• Unwinding Technique
• Cranial Hand contact on the greater wings to
  monitor motion
• Release will follow from a forceful flexion
  motion that can be felt By the cranial hand

Craniosacrale Osteopathie II, p.99
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Facilitators

• Do not try to go through the venous sinus
  drainage technique during the presentation. It
  takes too long
• Students can be given a handout of it to take
  home for practice.