Letters to the Editor  |   December 2010
Author Affiliations
  • Karen M. Steele, DO, FAAO
    Associate Professor and Section Head of Osteopathic Practice and Neuromusculoskeletal Medicine, University of New England College of Osteopathic Medicine, Biddeford, Maine
    Professor and Associate Dean for Osteopathic Medical Education, West Virginia School of Osteopathic Medicine, Lewisburg
Article Information
Ophthalmology and Otolaryngology / Pediatrics
Letters to the Editor   |   December 2010
The Journal of the American Osteopathic Association, December 2010, Vol. 110, 739-740. doi:
The Journal of the American Osteopathic Association, December 2010, Vol. 110, 739-740. doi:
We thank Student Doctor Prakash and Dr Michalik for their thoughtful response to our brief report,1 which described our experiences with a clinical trial. Although the well-known details of the anatomic structure of the pediatric eustachian tube and middle ear lymphatic system are indeed important in constructing a clinical trial of osteopathic manipulative medicine (OMM), we did not believe that these details were appropriate to include in a report intended to describe our experiences in implementing such a trial. 
Prakash and Michalik correctly identified what we thought to be the most important observation—the difference in recruitment between the two referral/treatment sites. We attributed this discrepancy to the presence of an onsite research assistant at site B and to the loss of three of the five committed referring providers at site A.1 
Furthermore, we agree with the commentary by Prakash and Michalik on Galbreath treatment and anterior cervical mobilization when used with older children. However, these techniques were not included in the previously published study upon which our research was based,2 a study that demonstrated statistical significance in outcomes for young children treated with a similar OMM protocol. In our experience, Galbreath treatment has not been found to be as helpful for treatment of very young children with otitis media as it is for older children. This lack of efficacy may be the result of anatomic differences between younger and older children in the mandible, hyoid bone, tensor veli palatini muscle, and pterygoid processes3-7 and the subsequent effects of these differences on soft tissues. 
In regard to the treatment protocol, Prakash and Michalik seem to be under the impression that the OMM techniques used in our study1 varied between subjects. The OMM protocol that we used was the same for all subjects and was designed with the following three goals in mind: 
  1. To use techniques that have some evidence of clinical effectiveness and that are commonly taught in colleges of osteopathic medicine (COMs). The techniques and treatment intervals chosen had been used by one or more treatment providers in a previous study2 and are known to be commonly taught in COMs.
  2. To address the key areas of somatic dysfunction in children with otitis media, based on a review of published literature and of unpublished documentation from previous otitis media studies.
  3. To use techniques that take less than 15 minutes to perform.
Our treatment protocol will be elaborated upon in our final report. Although there are many OMM techniques and combinations of techniques that may be helpful to children with otitis media, the protocol tested in our study1 was designed to meet the aforementioned criteria. 
Prakash and Michalik suggest that the use of otoscopic (ie, provider) visualization to confirm or refute tympanometry findings might decrease the number of unreadable tympanometry evaluations. This method could well be a useful addition to future studies though—as noted by Prakash and Michalik—it would introduce a level of clinical bias. Moreover, tympanometry and acoustic reflectometry are typically used as diagnostic techniques for children when otoscopic examination results are ambiguous—not vice versa.8 Although a comparison of otoscopic visualization vs “gold-standard” tympanometry and acoustic reflectometry might be an interesting project, in our experience the amount of infant crying and noncompliance is directly proportional to the probability of an unreadable tympanometry recording and an ambiguous otoscopy finding. 
Very few studies have been published evaluating the clinical efficacy of OMM in children, and there is a strong need for many more such studies. We are grateful for the interest that Student Doctor Prakash and Dr Michalik have shown in our brief report,1 and we hope they will join the ranks of those of us who are interested in studying the use of OMM in children. 
Steele KM, Viola J, Burns E, Carreiro JE. Brief report of a clinical trial on the duration of middle ear effusion in young children using a standardized osteopathic manipulative medicine protocol. J Am Osteopath Assoc. 2010;110(5):278-284. Accessed October 28, 2010.
Mills MV, Henley CE, Barnes LL, Carreiro JE, Degenhardt BF. The use of osteopathic manipulative treatment as adjuvant therapy in children with recurrent acute otitis media. Arch Pediatr Adolesc Med.. (2003). ;157(9):861-866.
Bosma JF. Anatomy of the Infant Head. Baltimore, MD: Johns Hopkins University Press; 1986:423-443.
Rood SR. The morphology of M. tensor veli palatini in the five-month human fetus. Am J Anat. 1973;138(2):191-195.
Rood SR, Doyle WJ. Morphology of tensor veli palatini, tensor tympani, and dilatator tubae muscles. Ann Otol Rhinol Laryngol. 1978;87(2 pt 1): 202-210.
Ishijima K, Sando I, Balaban C, Suzuki C, Takasaki K. Length of the eustachian tube and its postnatal development: computer-aided three-dimensional reconstruction and measurement study. Ann Otol Rhinol Laryngol.. (2000). ;109(6):542-548.
Carreiro JE. An Osteopathic Approach to Children. 2nd ed. Edinburgh, Scotland: Churchill Livingston Publishers; 2009:67-70,185-192.
Klein JO. Management of otitis media: 2000 and beyond. Pediatr Infect Dis J.. (2000). ;19(4):383-387.