An Osteopathic Approach to Torticollis, Plagiocephaly, and Otitis MediaOnline PPT 2/9&12/15Angela Branda, DO

ObjectivesReview and Define common pediatric presentations: Plagiocephaly, Torticollis, and Otitis Media

Explain the anatomy behind these problems, and why they are commonly seen in Pediatrics

Review current diagnosis and treatment of these problems

Identify common Osteopathic strains and considerations within these presentations

Explain how the incorporation of OMT can best be used in the treatment of these conditions

TorticollisDefinition - a malposition of the neck where the neck is sidebent in one direction and the head is rotated in the other

This is acutally a sign rather than a disease itself, and can be caused by many things

•Typically it involves spasm of the sternocleidomastoid, though it can involve the scalenes as well (which then causes rib dysfunctions)

Soo, we may have caused it a little..

1992 APA “Back to Sleep” program – recommendation that babies only be placed on their backs when being put to sleep

Decreased incidence of Sudden Infant Death Syndrome (SIDS) by 40%Increased incidence of Plagiocephaly 6-foldIncreased incicence of Congenital Muscular Torticollis (CMT) by 84%

Note – CMT is defined as torticollis that develops within the first 8 weeks of life, and may not be evident at birth

Often pt’s sleeping on their backs will have a tendency to turn their head to the same side, resulting in tightening of the opposite SCM, and pressure on one part of the skull repeatedly

However, these problems are reversible, whereas SIDS is not, so the recommendation is still important!!! It just requires more education on ways to prevent these other problems (see more below)

What else can cause Toricollis?

NeurologicVisual disturbances (nystagmus, superior oblique paresis)Dystonic drug reactions (phenothiazines, haloperidol, metoclopramide)Cervical cord tumorPosterior fossa brain tumorSyringomyeliaWilson diseaseDystonia musculorum deformansSpasmus nutans

CongenitalMuscular torticollisPositional deformationHemivertebra (cervical spine)Unilateral atlanto-occipital fusionKlippel-Feil syndromeUnilateral absence of SCMPterygium colli

TraumaMuscular injury (cervical muscles)Atlanto-occipital subluxationAtlantoaxial subluxationC2-3 subluxationRotary subluxationFractures

InflammationCervical lymphadenitisRetropharyngeal abscessCervical vertebral osteomyelitisRheumatoid arthritisSpontaneous (hyperemia, edema) subluxation with adjacent head and neck infection (rotary subluxation syndrome)Upper lobe pneumonia

OtherAcute cervical disk calcificationSandifer syndrome (gastroesophageal reflux, hiatal hernia)Benign paroxysmal torticollisBone tumors (eosinophilic granuloma)Soft tissue tumor

CMT with SCM Tumor:

Pseudotumor of Infancy

• Aka: Fibromatosis Colli

• Fibrotic muscular tumor of the SCM– Myoblasts, fibroblasts,

mesenchymal cells

• General fibrosis and thickening of SCM

• Can progress to complete fibrosis and contracture of SCM if left untreated

What do we do for it?• Treatment of Torticollis is multifactorial

• If there is an underlying cause other than muscle spasm, that obviously needs to be addressed (see above HUGE differential list)

• Identifying cranial strains (commonly the cranial base, occiput/condyles) is important as this may be a primary cause

• Testing of both SCM and scalenes and treatment of both as needed, as well as interplay of any cervical/rib/thoracic inlet/thorax strains as all of these can affect the muscles at their attachments

What can parents do?• Education of the parents is key, as often these issues

are related to positioning at rest

• Encouraging supervised tummy time (once baby is old enough – around 3 months) to strengthen extensors and reduce time spent turned to one side

• Placement of mobiles/mirrors/etc on other side of the crib to encourage looking the other way when sleeping (cushions and pillows in the crib are not recommended as they are a suffocation risk)

• Play time in which toys and sounds are used to encourage baby to turn their head to the opposite direction

• VERY GENTLE stretching at home

Plagiocephaly• Definition - abnormal shape/deformity of the skull

• Can be differentiated into primary and secondary– Primary plagiocephaly - skull deformation due to

intrauterine lie or as a result of the forces of labor or delivery. It can be noticed from birth or soon after.

– Secondary plagiocephaly - develops secondary to forces from a torticollis or persistent abnormal posturing. Not usually noticed until the infant is several months old

• MUST be on the lookout for Craniosynostosis!!!

Craniosynostosis• Craniosynostosis is a premature fusion of the cranial

sutures resulting in abnormal head shape that has features that are decidedly different from that of plagiocephaly

• It can be part of a genetic syndrome, in which several other features of that syndrome are present

• Can be non-syndromic –which usually only involves one suture line and is related to mechanical forces (abnormal stretch forces signaling premature ossification

• Most common suture involved is the Saggital Suture (scaphocephaly)

• Growth along that suture line will cease, but growth of the non-fused areas will continue, resulting in significant deformity of the skull

How will I know?• Signs that make you worry about craniosynostosis

rather than simple plagiocephaly:– Slowed growth of head circumference (may stop

completely)– Palpable bony ridge along fused suture line– Worsening of the deformity– Developmental delay– Abnormal hair growth pattern

• Recommended CT for evaluation (this condition is very serious and worth the radiation – but need a high suspicion to go for it)

• Treatment is surgical (and usually looks really drastic!!)

Plagiocephaly SynostosisParallelogram Trapezoid

Growth throughout not restricted, just shifted. Will still have growth along all suture lines.

Growth across fused suture halted, with narrowing of that line and exaggeration along all others.

Plagiocephaly vs. Craniosynostosis

Parallelogram with some frontal bossing, but no restriction of growth along sutures

saggital

coronal Metopic

Restriction along growth of suture listed with pic

Okay, it’s just Plagiocephaly…..Now

what?• Causes of plagiocephaly are varried. Pt’s subjected to abnormal forces in utero, torticollis, trauma, consistent back sleeping, prolonged time in car seats without changing position, limited “tummy time” are all factors that can play into plagiocephaly.

• Treating the patient first involves identifying reversible causes and educating parents on ways to help at home– Having pt’s change position more often (back-to-sleep still

recommended for reduction of SIDS), more tummy time, playing with baby to make them turn their head to the other side (or putting toys on the other side of the crib to make them turn)

– Many of the positional issues used for treatment of torticollis are also used in plagiocephaly, as the two are often interrelated.

More fun with Treatment

• Severe/Unresolving Plagiocephaly may require helmet therapy– Pt is fitted for a helmet that places gentle pressure

on areas with bossing while creating space over flattened areas for them to expand

– As the pt’s head grows, it will idealy develp into the areas with space, resolving the flattening

– Helmets are not static, and are modified regularly as the pt’s head changes

– Can result in pressure sores (though they are much softer than you might think)

Where does OMT fit in?

• As underlying cranial strains can lead to plagiocephaly, addressing these early can allow for faster resolution

• Plagiocephaly that develops due to position can cause further craniosacral strains, and prevent resolution or cause other problems, and need to be addressed

• Other mechanical causes, such as torticollis causing a positioning issue are easily addressed with treatment

• BLT, BMT, soft tissue, myofascial unwinding are all very effective treatments – no specific thing to treat – identify each patient’s strains and address them to optimize movement

• Pt’s receiving helmet therapy still should be treated with OMT – they work well in conjunction with one-another (ideally helmet adjustments will happen after a treatment to promote growth when the recent strains have been released)

Suggested Protocol

• If no change in shape with OMT, PT, and positioning by 4-8 weeks– Obtain x-rays of sutures

• Obtain 3D CT of head– If x-rays of sutures are poorly

visualized

• If sutures are patent begin head orthosis (helmet) treatment (best if initiated b/w 4 - 6 months of age)

• NOTE: 85% of post-natal growth happens in 1st year of life; 10% of PHD children will have cosmetic fascial deformities

Helmet therapy

Otitis Media• Infection of the middle ear, most commonly viral or bacterial

• Most common bacteria are: Strep pneumonaie, non-typeable H. influenzae, Moraxella cattharalis

• Classified as Acute (AOM), chronic, or recurrent OM with effusion– Effusion can remain after an infection for up to 3 months in 10%

of children (up to 1 month in 40%)

• First line antibiotic treatment is high dose Amoxicillin

• AAP guidelines published February 2013 discuss the proper diagnosis and treatment of AOM, including when observation is appropriate vs. introduction of antibiotics (this inadvertantly happens to be a GREAT time to introduce OMT!!! )

The Trouble with Anatomy• The anatomy of the ear in

childhood sets the stage for more frequent ear infections

• Eustachian tubes– Run from the middle ear,

along the petrous portion of the temporal bone, across the petrosphenoidal junction, past the palatine muscles to end in the nasopharynx

– Serve to drain fluid accumulated in the middle ear, and to allow air movement to regulate pressure (think airplane)

• The narrowest point in the pathway is over the petrosphenoidal junction, where the tube is surrounded by a sling of connective tissue– Myofascial and cranial strains

through this area can impede function of the eustacian tube

Their heads are just different• The development of the skull from chilhood to adulthood

also changes the location of the ear in relation to the nasopharynx. In children, the eustachian tube is much more horizontal– As we grow, the face elongates forward and up/down and

the ears orient higher in the skull. This results in more angle to the eustachian tube, allowing gravity to assist with drainage (this becomes more evident after 6yo, at which time we notice a decline in the number of ear infections in general)

EAC

Muscle Trouble• The tensor veli palatini attaches to the lateral wall of

the eustachian tube at the nasopharynx, and opens the tube when it contracts– It works to pump the tube to assist with drainage– Floppy musculature can result in difficulty opening the

tube and decreased drainage– In kids, hypertonicity of the muscle can also distort the

tube because it is more pliable and result in poor drainage from positioning

• The Medial Pterygoid (not usually associated with the eustachian tube), runs right by the opening– Can have fibrous attachments to the opening of the tube– When contracted, the bulk of the muscle can obstruct

the eustachian tube (hypertonicity and increased muscle bulk can significantly affect drainage)

I’m a little stuffy • The mucosa of the middle ear

and eustacian tube is similar to that of the nasopharynx – lymphoid tissue with secratory glands– So when the nose gets

irritated and produces more mucous, so does the ear

– Chronic stimulation results in increased viscosity of the mucous produced

– The longer it sits in the ear, the more likely it is to breed nice, healthy bacteria (not so good for the host – major ear infection!!!)

OMT to the Rescue!!!• OMT in the presence of AOM is used to promote

drainage of the fluid and reduction in viscosity of that fluid

• Common areas to treat are cranial strains, the medial pterygoid, cervical musculature, thoracic inlet, OA/AA, upper thoracics (autonomic influences!!!)

• This is very helpful in reducing the amount of fluid accumulation in the middle ear, allowing for faster resolution of infection, and reduction of recurrence– This does not replace the use of antibiotics, which are

still appropriate for some patients/situations

References• Behrman: Nelson Textbook of Pediatrics, 18th ed.

• Carreiro, J. An Osteopathic Approach to Children, 1st ed.

• American Academy of Pediatrics (www.aap.org)

• Allan S. Lieberthal A. S., et al;The Diagnosis and Management of Acute Otitis Media; Pediatrics; originally published online February 25, 2013; DOI: 10.1542/peds.2012-3488

• http://www.thecraniofacialcenter.org/index.html

• http://emedicine.medscape.com/article/994656-overview