Chiropractic approach to the ear

Eyes can water or become dry– which gets our attention. Noses can clog. Throats get sore. But when something goes awry with our ears, proper diagnosis may require a variety of tests. Ear problems can be excruciatingly painful, especially in children; in other cases, a disorder related to the ear can render a patient so dizzy that simply standing up is a challenge.

For some conditions of the ear, chiropractic adjustment/spinal manipulation and adjunctive therapies offer relief when traditional therapies have failed.

Curbing the Leading Childhood Ailment

If a child makes it through elementary school without at least one ear infection, that child is lucky. With 10 million new cases every year, ear infections (otitis media) are the most common illness affecting babies and young children and the No. 1 reason for visits to the pediatrician– accounting for over 35 percent of all pediatric visits. Almost half of all children will have at least one middle ear infection before they’re a year old, and two-thirds of them will have had at least one such infection by age 3.

With symptoms that can include ear pain, fever, and irritability, otitis media can be either bacterial or viral in origin, and frequently results from another illness such as a cold. For many children, it can become a chronic problem, requiring treatment year after year, and putting the child at risk of permanent hearing damage and associated speech and developmental problems.

Standard treatment for most cases of otitis media is with antibiotics, which can be effective if the culprit is bacterial (antibiotics, of course, do nothing to fight off viruses). But antibiotics aren’t the powerhouses against ear infections that some might think. A 1994 meta-analysis of 33 studies dealing with the use of antibiotics for the treatment of acute otitis media, carried out jointly by George Washington University and the University of Minnesota, found that drugs have only about a 14 percent advantage over the body’s own immune system.1 A Netherlands study2 found little difference in long-term outcome between children with ear infections treated with antibiotics and those given a placebo. And repeated doses of antibiotics can lead to drug-resistant bacteria that scoff at the drugs, while leaving the child screaming in pain.

Frequent ear infections are also the second most common reason for surgery in children under two (with circumcision being the first). In severe cases -for example, when fluids from an ear infection haven’t cleared from the ear after several months, and hearing is affected- specialists sometimes prescribe a surgical intervention called a myringotomy and tympanostomy, which involves the creation of a small surgical opening in the eardrum in order 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 it is an effective treatment, it has to be repeated in some 20 to 30 percent of cases. And this kind of surgery is not to be taken lightly-if for no other reason than it requires general anesthesia, never a minor thing in a small child. If the infection persists even after tube placement and removal, children sometimes undergo adenoidectomy (surgical removal of the adenoids) -an option whose effectiveness is limited mostly to the first year after surgery.3

Before yet another round of maybe-they’ll-workand-maybe-they-won’t antibiotics or the drastic step of surgery, more parents are considering chiropractic to help children with chronic ear infections. Joan Fallon, DC, who practices in Yonkers, New York, and serves on the faculties of Palmer College of Chiropractic and New York Chiropractic College, has published research showing a remarkable success rate for chiropractic adjustments in resolving otitis media. Her pilot study involved 332 children with chronic ear infections between the ages of 27 days and 5 years. After receiving a series of chiropractic adjustments, nearly 80 percent of the children treated were free of ear infections for at least the sixmonth period following their initial visits (a period that also included maintenance treatments every four to six weeks).4 That jibes with the results of an earlier retrospective study, published in 1996, which found that chiropractic improved the condition of 93 percent of children with ear infections — 75 percent within 10 days or less and 43 percent with only one or two treatments.5

“Chiropractic mobilizes drainage of the ear in children, and if they can continue to drain without a buildup of fluid and subsequent infection, they build up their own antibodies and recover more quickly,” explains Dr. Fallon. She’d like to see her pilot study used as a basis for larger-scale trials of chiropractic as a therapeutic modality for otitis media.

Dr. Fallon uses primarily upper-cervical manipulation on children with otitis media, focusing particularly on the occiput and atlas. “The middle ear is contiguous with the mastoid air cells and all the way down through the Eustachian tube -it’s one big air system,” she says. “Adjusting the occiput, in particular, will change the pressure in that system and get the middle ear to drain. Depending on how chronic it’s been and depending on where they are in their cycle of antibiotics, children generally need to get through one bout of fluid and fight it off themselves.” That means, for the average child, between six and eight treatments. If a child’s case is acute, Dr. Fallon will check the ear every day, using a tympanogram to measure the ear and track the movement of the eardrum to make sure that it’s draining. “I’ll do adjustments every day or every other day for a couple of days if they’re acute, and then decrease frequency over time.”

Dr. Fallon, whose research garnered her the acclaim of childrearing magazines like Parenting and Baby Talk, often wins a patient for life when she treats a child for otitis media. “Once they fight it themselves, my kids tend to do very well and stay away from ear infections completely. Unless there are environmental factors like smoking in the house, an abnormally shaped Eustachian tube, or something like that, they do very well,” she says.

“I have two large pediatric groups that refer to me on a regular basis. In the wintertime, it can be as many as five or six new children each week from each group, when otitis is most prevalent. I do it all day long — sometimes it seems like in wintertime that’s all I do,” says Dr. Fallon. “It’s safe and effective and something that parents should try, certainly before inserting tubes in their children’s ears. It’s something that a doctor of chiropractic can do without any specialized training, although certainly some practitioners are more comfortable working with children than others.”

Dizziness

Another area where problems related to the ear may be helped by chiropractic is that wide-open catch-all category known generally as “dizziness.” When a doctor of chiropractic sees a patient who’s complaining of episodes of dizziness, the first step is to figure out exactly what that patient means. “I get dizzy” can point to a wide range of problems, but in general, says Rand Swenson, DC, MD, PhD, there are three distinct things that patients mean when they speak of dizziness. “First, there is vertigo, defined as an illusion of movement.

Second, there is presyncope, which is lightheadedness, faintness, or wooziness -in general, the feeling that you might get if you stand up too quickly,” says Dr. Swenson, an associate professor of neurology and anatomy at Dartmouth Medical School and a member of the post-graduate faculty for National Chiropractic College. “Third, there is disequilibrium, or a sense of instability when walking.” Most often, vertigo — the illusion of movement-is the one that’s related either to problems in the ear and/or to cervical spine problems, and is responsive to chiropractic treatment.

How do you differentiate between cervicogenic vertigo, caused by neck problems, and benign paroxysmal positional vertigo (BPPV), frequently caused by problems in the inner ear? A fairly simple test should provide the answer. First, have the patient sit on a chair or stool that can rotate, like a desk chair. Then, stand behind the patient and ask him or her to rotate the head from side to side fairly quickly a couple of times. “If that makes the vertigo worse -if a patient gets dizzier- the cause could be either from the neck or the inner ear,” says Bill Lauretti, DC, a chiropractor in private practice in Gaithersburg, Maryland, and a Maryland delegate to the ACA. “You don’t know yet, because you’ve moved the head relative to the neck, but you’ve also moved the inner ear, sloshing the liquid around.” In step two, the doctor stands behind the patient and holds the head still so that the nose remains pointed in the same direction. The patient then rotates the patient’s body on the stool, while the head stays in one place. “If that makes a patient dizzy, it indicates cervicogenic vertigo because you’re not sloshing the fluid in the inner ear around, but you are moving the neck so it suggests that that’s where the issue is,” Dr. Lauretti says.

Cervicogenic vertigo is frequently treated by chiropractic, but BPPV can sometimes also be relieved by the chiropractic adjustment/spinal manipulation. In dealing with this type of vertigo, says Dr. Lauretti, it helps to understand the theories behind it. “It’s believed that it has to do with the proprioception from the upper-cervical spine. In order to sense our body in space, there are a couple of different ways that input comes into the brain.” One is through the semicircular canals of the ear, which are filled with fluid; Dr. Lauretti compares them to little carpenter’s levels. “There are actually three `bubble levels,’ and they’re perpendicular to each other, so you can tell where your head is in all three spatial planes.” If you’re standing up straight and bending your neck forward, for example, fluid will move around in these “bubble levels” and tell the brain that your head is tilting forward. If, on the other hand, you start to fall forward, they tell your brain that your body is moving with your head -that you’re going to fall.”

But occasionally, says Dr. Swenson, small calcium carbonate crystals can become loose in the inner ear and throw off the readings the “bubble levels” get. “In certain positions, they can activate the balance receptors in the inner ear, and that usually gives rise to some pretty severe spinning. This is most common in people who are lying down with one ear down,” he says. “It typically manifests with a slight delay of a couple of seconds followed by vertigo so severe that people often wind up grabbing hold of things and sometimes feel sick to their stomachs even after it’s passed.” This type of vertigo episode usually lasts from 30 to 45 seconds. If you’ve already tested your dizzy patient on a rotating stool and the problem seems related to the ear rather than cervicogenic, having the patient lie on the side with one ear down is a further test-known in Europe as the Nylan-Barany maneuver and in Britain as the Hall-Pike maneuver-that can help isolate BPPV. “Occasionally, putting somebody down on a high-low table can also provoke these attacks, or having people sit up after they’ve been lying down,” Dr. Swenson says. “But the point is, they’re provoked by head movements, rather than specifically by neck movements.”

Clearing the Ear

If you’re dealing with benign paroxysmal positional vertigo, the patient can be put through a series of movements called the canalith repositioning procedure (CRP) or the Epley maneuver, after Oregon DC John Epley, the first to describe it. Studies have shown CRP to be an effective treatment for this type of vertigo.6 “Basically, you put the patient through a series of positions to try to move the loose canaliths into a different position in the inner ear, so that they’re not piled up against the receptors in the semicircular canals,” says Dr. Swenson. “But before doing this for the first time, the person needs a thorough exam to make sure that’s what the problem is.”

The practitioner starts the Epley maneuver, or CRP, by putting the patient back in the position that makes him or her dizzy. “While the patient is lying down, you then turn the head 45 degrees away from the affected ear,” Dr. Swenson explains. “Then you roll the patient up on their side, so they can look 45 degrees down toward the floor opposite the affected ear.” From that position, the patient is helped to sit up quickly, upright with the head in a neutral position, and finally the head is directed 45 degrees downward with the patient’s gaze on the knees. “Those positions, incidentally, will often make the person dizzy each time they change. They’re held in each position until they stop being dizzy, then you move on to the next position. Once you’re finished, let the patient sit for five or ten minutes.”

After putting the patient through the Epley maneuver, the doctor of chiropractic repeats the Nylan-Barany maneuver to test whether or not the repositioning has solved the problem. “If it has, you let the patient go home,” says Dr. Swenson. “If it provokes dizziness again, then go back through the whole series. Sometimes you’ll have to do it two or three times.” He notes that for patients who don’t respond as quickly, the Epley maneuver is sometimes more effective if the head is vibrated throughout the procedure, which can be done using any vibration device. “Typically, they’re asked to sleep the first night or so in a recliner rather than flat, and once they’ve gotten through that point, they’re usually cured,” says Dr. Swenson, who notes that the condition does still have a tendency to recur from time to time because it happens in people who have a predisposition to loose canaliths. “Certain things like head injury can provoke it; it’s sometimes seen after whiplash injuries, and it does increase in frequency with age. Sometimes we can train patients to do these positions at home if it happens frequently.”

What if the vertigo is not BPPV, but cervicogenic? There are, explains Dr. Lauretti, three categories of cervicogenic vertigo. “The first is caused by an abnormal neck reflex. The nerves in the upper neck that tell your brain where your body is relative to your head -there’s something wrong with that input system.” Causes could include muscular injury or inflammation of nerves. “It’s a fairly common condition after an auto accident involving mild neck injuries and soft-tissue injuries, such as whiplash. You could call it either a joint or muscle problem,” Dr. Lauretti says. “Muscle receptors in the upper neck have direct input into the vestibular complex of the brain, so that appears to be the basis for this particular condition.” This type of cervicogenic vertigo is the version that is amenable to chiropractic treatment. “It can be treated with standard adjustments and rehabilitation,” says Dr. Swenson. “If it’s an ongoing, chronic problem, depending on how bad someone’s neck is, they’ll probably need more rehabilitative treatment. If it’s recent and acute, they’re more likely to respond to chiropractic adjustments.”

In the second case, cervicogenic vertigo can be traced to an irritation of the central sympathetic nervous system. “That’s the part of the nervous system where the ‘fight or flight’ response is housed,” Dr. Lauretti explains. “If it’s constantly being irritated or stimulated, it’s putting out a barrage of signals coming from that upper-neck area. That could make you nauseous and queasy. It’s probably best characterized not so much as true vertigo, but rather as just generalized nausea.

Danger Zone

An additional category of vertigo, and one that doctors of chiropractic should be particularly concerned about, is compression of the vertebral artery. “Since the artery brings blood to the base of the brain, and structures there help us to maintain balance, decreases in the blood flow to that area can lead to dizziness,” Dr. Lauretti says. “This is one of the issues that we have to be able to differentiate when treating patients with vertigo because it can be very serious. If you adjust a patient and it truly is a case of vertebral artery compression, you take the chance that when you’re working on the upper neck, you’re going to do further damage to the artery and cause a stroke. It’s an exceptionally rare occurrence, but in a case where a patient has vertigo along with other signs suggesting vertebral artery compromise, you need to be especially careful.”

With cervicogenic vertigo caused by vertebral artery compression, there are invariably other signs pointing to this serious situation, Drs. Lauretti and Swenson agree. “There will be visual symptoms, problems with coordination, difficulties with speech or swallowing, and/or sensory changes,” Dr. Swenson notes. The patient’s reaction to the spinning stool test will also be different. “Typically, vertigo caused by vertebral artery compression takes some time to build up when the person is turned. It doesn’t start instantly, but rather builds as the person remains in that situation. It gradually escalates,” he says. “In the case of cervical vertigo, which comes from an imbalance or abnormalities in input from sensory receptors in the neck, probably mostly in the muscles of the neck, the dizziness typically will occur quite quickly when the neck is turned, and it’ll stay pretty stationary or stable as they’re held in that position.”

If vertebral artery compression appears to be involved, says Dr. Swenson, “I’d probably refer someone with those symptoms right away.” The only way to definitively differentiate this condition is through a cervical magnetic resonance angiogram, an expensive test that involves some risk, and not something to be done as a routine screening. “That’s for somebody who needs specialty evaluation of the cranial circulation before treatment, 11 agrees Dr. Lauretti.

“I think it’s important that we make an effort to diagnose these cases properly and to treat them,” he says. “Studies show that the treatment for most cervicogenic vertigo, except for the vertebral artery compression, are very effective. There’s often a tendency for these patients, if they haven’t been to a doctor of chiropractic, to be misdiagnosed and not be treated properly. They can’t walk, they can’t drive, they’re always dizzy, and they feel like the body’s not properly hooked up to the head. We have a very important role to play in alleviating that.”

References

1. Cantekin EI. Antibiotics to prevent acute otits media and to treat otits media with effusion. JAMA 1994, 272(3): 203-4.

2. Damoiseaux RA, van Balen FA,

Hoes AW, Verbeij TJ, de Melker RA. Primary care based randomised, double blind trial of amoxicillin versus placebo for acute otits media in children aged under 2 years. BMJ Volume:320 Issue:7231, Page:350-4 Year:2000 Feb 5.

3. Paradte JL, Bltone CD, Colborn DK, Bernard BS, Smith CG, Rockette HE, Kurd-Lasky M Adenoidectomy and adenotondillectomy for recurrent acute otitis media: parallel randomized clinical trials in children not previously treated with tympanostomy tubes. JAMA 1999, 282(10):945-53. Volume:282.

4. Fallon JM The Role of the Chiropractic Adjustment in the Care and Treatment of 332 Chidren with Otits Media. Journal of Clincal

Chiropractic Pediatrica. 1997; 2(2):167-183.

5. Froehle RM, Ear infection: a retrospective study examining improvement from chiropractic care and analyzing for influencg factors. J Manipulative Physiol Ther 1996 Mar-Apr;19 (3):169- 77.

6. Froehling DA, Bowen JM et aL The Canalith Repositoning Procedure for the Treatment of Benign Paroxysmal Positional Vertigo: A Controlled Trial. Mayo Clin Proc 2000,75:695-700

7. Fitz-Ritson D. Assesment of Cervicogenic Vertigo. J Manipulative Physiol Ther 1991 Mar-Apr; 14(5):193.

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