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.
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.
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.
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.