Our next speaker is Dr. Murray Berkowitz, who is part of the PCOM College of Osteopathic Medicine at Suwannee, Georgia, the Georgia campus, and he has most recently been tenured as a full professor of neuromuscular skeletal muscle medicine and osteopathic manipulative medicine. He previously worked for the Virginia Department of Health as director of a three-county health district and was a visiting assistant professor of computer and information sciences at Tucson University in Maryland. Before attending medical school, he served in numerous assignments in the U.S. Army and U.S. Air Force. Dr. Berkowitz is a disabled veteran and is a medically retired Army lieutenant colonel due to service-connected combat-related disabilities. He attended the College of Osteopathic Medicine and Surgery in Des Moines, received his DO degree, and received a master's of public health degree from Johns Hopkins University. He's been a lifelong student. He is a member of multiple organizations and has served numerous leadership positions. He has published manuscripts, papers, and has given many presentations. He consults in the area of occupational medicine, emergency and disaster planning, and has been a national speaker. Let's welcome Dr. Berkowitz to the topic of osteopathic manipulative medicine for treating patients with barotitis. Thanks, everyone, and I hope everybody out there in the virtual universe can hear me just as well as everybody else in the room here can hear me. All righty, guys, and if it's not obvious from the slide, I've stepped away from academic medicine, and I am back in private practice, and to compliment our colleague who just spoke who's in semi-retirement, so am I. I only practice less than 20 hours a week. Therefore, my malpractice is less than half, or is half, I should say. Some of these slides are provided by Will Ehrenfeuchter, who is a colleague of mine, and the objectives are, as you can see here, to be able to describe the functional anatomy related to barotitis and its osteopathic manipulative treatment, and be able to describe some OMT techniques that you can use to treat patients who have barotitis, and to be able to describe OMT techniques appropriate for self-treatment of acute barotitis. So what are you going to do to help people? Oh, by the way, before I forget, I have absolutely no conflicts of interest or anything to declare, and I'm certainly not talking about drugs. So barotitis, also called barotitis media, airplane ear, barotrauma, barotitis media, etc. And who's susceptible? Basically, anyone who flies or dives, and that includes not only the pilots or aviators, to use the, you know, Army and Navy, Marine Corps term, flight crew, the navigators or naval flight officers, the flight engineers, the load masters, and the flight attendants on commercial aircraft, and the passengers, okay? So they all have a possibility of being susceptible to barotitis. Epidemiologically, and unfortunately, Howard's not here, so barotitis has been present, as it turns out, as long as there's been people taking flight. And this is by Brian and Treble et al, and they found that Jacques Charles, in 1783, he was the French physicist who made the first free ascent in a hydrogen balloon, and described suffering from severe right ear pain as he went fairly quickly up to a height of about three kilometers, three thousand meters above the ground level, and it was only relieved upon descent. In terms of the incidence, depending upon how you read it, and how they calculated things, incidence varies, it seems to be between eight percent and 17 percent in terms of annual incidence. The incidence in passengers that were studied by Stengerup, Kloker, and all, they talked about point prevalence of barotitis, and they found that the passengers, about 14 percent, suffered from barotitis, and that was reduced to about six percent in the passengers who were able to perform a nasal balloon inflation during descent. There was also an altitude chamber study by Landolphi, Torchia, et cetera, and basically they found that there was a prevalence, as they called it, really an incidence of about 2.4 percent. What they really ended up saying was that it's basically necessary to perform a physical exam on the aircrew before they take their periodic chamber rides. I know that we used to have an additional three-day thing on that in the Air Force, and then like every third year you had to again cert in the chamber. There was a mathematical model simulation, and they found what's called a buffering mechanism, and the idea there was that they found decreased efficiency of the muscle-assisted eustachian tube opening based upon their mathematical model, and buffering systems may explain why some children and some adults who have poor eustachian tube function do not experience middle-ear barotrauma. Again, this is based on a 2005 article by Kanick and Doyle, and this was published in the Journal of Applied Physiology. So what's the etiology? What causes barotrauma? Basically, it is the pressure change between the external environment and the middle ear. The eustachian tube ends up becoming blocked, and air ends up building up inside the middle ear. There's tissue injury, which leads to swelling, which leads to the pain that the person feels, and there are a lot of other things that can happen as a result of that. Let's just quickly review the anatomy. Again, here we have a tympanic membrane. You've got the external auditory canal and the auricle. You've got the three bones, the malleus, the incus, and the stapes. Basically, again, the stapes is attached to the oval window, and you have the semicircular canals, and those lead to the cochlear nerve and the vestibular nerve, and the cochlear, of course, contains all of the nerve endings that will give us our sound and our ability to basically go through the semicircular canals are going to give us our positioning vectors in space and three dimensions. Of course, what happens here is this becomes blocked. There's a buildup of pressure inside here, injures the soft tissue in here, and again, it just can't get out. When does this happen? Usually, ascending or descending, so takeoff or landing. It happens in flight, scuba diving, hyperbaric oxygen chambers, so patients undergoing that kind of treatment. Also, hypobaric or altitude chambers. Riding fast-moving elevators has been an occasional cause or source of people suffering from barotitis or going up and down mountains, and then, of course, something for those of us who've been in the military, explosions, but that's not restricted to people in the military. It's just more common, and, of course, these are exacerbated by a person having a cold, sinusitis, allergic rhinitis, otitis media, or sleeping. For some reason, people tend to be sleeping on the aircraft. They can't take active measures to release the pressure that's building up, and that's both the passenger and crew members who have the opportunity to sleep on the flight during takeoff, so the number one prevention technique is don't fly or dive when you're sick. That's the number one thing. Don't sleep during takeoff or landing. Well, it's pretty hard when the flight attendant comes around and tells you to put your tray table up, okay, unless you're like me. What I'll do is I'll put my wife's tray table up so that she won't be disturbed if she's sleeping, but I only do that if she's not suffering a head cold or anything like that. Decongestants 30 to 60 minutes before flight, nasal sprays, antihistamines, and the medications must be non-sedating in crew members. In passengers, we don't care, okay, but if you want to let them take a sedating kind of thing and they fall asleep, there's a problem. You don't want them taking it too soon before that. It'll put them to sleep, and they can't take any active measures. We'll talk about that later on. What do you do? You've got an acute barotitis in flight, yawning, swallowing, chewing gum, or performing the Valsalva maneuver, and again, that's where you close your mouth, take a breath in, close your mouth, pinch off your nose so you can't breathe out, and gently try to breathe outward, and basically, the idea is that that would then pop your tympanic membranes and release the pressure, okay? Here we go. So, when prevention and in-flight techniques are not effective, or if you will, what do you do when the person returns to terra firma post-flight? Okay, so let me go over your lymphatic functional anatomy here, and if you remember from med school or other things, you have the lymphatic capillaries collecting tubules, the lymphatic trunks, and the collecting ducts. These are, again, blind endothelial tubes. They run, the fibers run from the endothelial cells deep into the intracellular matrix, and preventing the collapse of those thin-walled and leaky vessels. Now, large pores allow proteins to enter, which cannot enter the vascular capillaries. So, again, this is considered part of our vascular system. The chest wall and the pora is drained by, or I should say, are drained by the intercostal trunks. The thoracic viscera drains to the mediastinal trunks. The head and neck drain to the jugular trunk. The arms drain to the subclavian trunk. The legs drain to the external iliac trunk, and the pelvis drains to the internal iliac trunk. The gastric trunk gets the liver, the spleen, the stomach, and the pancreas, as you can see. All right. So, this picture just shows the anatomy, and you can see, basically, oops, sorry about that. You can, here we go. You can see, sorry about that, guys. I was trying to get the, all right, we're going to forget about my trying to use the, I've got fat fingers. Oh, good. Thanks. Next one, next one, next one. Right there. There you go. Thanks. All right, guys. I was trying to use a pointer so you could see all of these lymph nodes and the lymph trunks coming up here, and again, you can only see the lymph trunk clearly on the right side compared to on the left side in the sketch here. Let me move onward. Just trying to do that. The cisterna chyle is a dilated saccule that marks the beginning of the thoracic duct, and this receives all of the lymph fluids from the lower extremities, the pelvis, and the abdomen. All right. The thoracic duct gets the cisterna chyle that I just mentioned, the left portion of the head and neck, the left arm, and the left lung. The largest lymph vessel, it is the largest lymph vessel in the body, and it has valves to prevent the backflow, as does the right lymphatic duct. It contains a layer of smooth muscle innervated by the sympathetic system, and that regulates the peristalsis movement of the larger lymph ducts. The thoracic duct lies directly against the vertebral column to the right side from the aortic hiatus to the level of about T4, about the sternal angle, and then at T4, it angles across the spine to the left side to continue to descend through the aortic arch, and it passes in front of the phrenic nerve behind the vagus. It exits the thorax through the superior thoracic aperture, makes a U-turn, and then joins the venous circulation at the junction of the jugular and subclavian veins, and it must traverse Simpsons fascia. If you remember, Simpsons fascia is the fascia that is at the level of the first rib, T1, and the superior portion of the sternum. The right lymphatic duct receives all liver lymph from the right head and neck, the right arm, the right thorax, and the heart and pericardium. All right, so you can see that there's the left does a lot of the body in general, and the right side does the heart, lungs, and the right upper extremity in the right hand. So how do the sympathetics get to the viscera of the head? And this basic diagram comes basically out of Kutchera and Kutchera's book on basically the systematic treatment using osteopathic medicine and for H, E, E, and T problems. The thoracic inlet, again, T1 and the R1 dysfunctions influence the scaling muscles in the head posture. You've got the manubrium sternal dysfunction, claviscular dysfunction, and contracture of Simpsons fascia. So basically, you've got to make sure you treat the inlet first before you can assure that you're going to get proper drainage from the lymph system as everything goes ultimately north of the fascia before it returns. Okay, so that's you got to unclog the big pipes, if you will, before you try to pump the smaller ones. All right, so there are a number of techniques you can use. One is anterior cervical arches. And basically, if you want, and Jeffrey has kindly volunteered to serve as a treatment model, and we can do this with him standing so that people can see him. Okay, and he told me that because it's all connected, I can treat in through the scrotum. And I told him, yeah, I can rip off that and, you know, we can confirm. Okay, so. Okay, these are how we would treat these anterior cervical arches, just moving them back and forth. Okay, ordinarily, I'd have the patient either seated, but more often than not, I'd have them lying supine, you know, on a table, and then I could move from one to the other. Now, don't go away, you're going to have others I'm going to treat you with. All right, great for pharyngitis, laryngitis. It's great for restoring and I've used this pretty effectively in restoring voice in laryngitis. Matter of fact, I used it reasonably effectively on myself. When I couldn't talk because of an acute laryngitis episode, and no, I did not have COVID. It was just the crud. And contraindications, head and neck cancers, anterior neck traumas. So if you've got fractures, or anything that you've got, you know, high hematomas, fractured cartilages, even in terms of that. And if you have a hypersensitive carotid sinus, there's another thing to avoid. So again, could be seated, could be supine, you can be doing this stuff. But again, I just showed you doing it standing. Again, cephalad part of the hand stabilizes the head, gently grasps the forehead, cradling the head on the cephalad hand. And typically, again, thumb and index finger and you just gently go back and forth, they form a horseshoe motion over the hyoid bone. Okay, work. And as you saw me demonstrate on Jeffrey, works his way up and down the length of the neck. And if there's crepitance between the anterior cartilaginous structures and the c-spine, the next may be flexed or extended in an effort to eliminate that because that's a sign of excess friction. And you can continue doing that for as short as 30 seconds as long as two minutes. Okay, there's a picture of the placement. So cervical chain drainage and the indications are any infectious disease of the head and neck structures. And the idea is to promote lymphatic drainage. Contraindications again, cervical cellulitis, head or neck cancers, and so on. Basically, again, patient is usually supine, head is going to be turned toward the treating physician with the physician treated at the side of the head or neck. And this other hand is going to be placed underneath the patient's head, elevated slightly. And then you end up using the fingers of the caudate hand to make broad contact with the flat of the fingers over the sternocleidomastoid muscle near the angle of the mandible. So that's the placement that you have there. So if I have him, I would have his head here, and I can just simply go along that. Remember, I would have had to have opened the substance fascia first before doing any of these kinds of techniques. Okay. Again, now auricular drainage. This is great. I don't know how many of you out there have kids, grandkids, or what have you. But when my younger grandson, who's now five, nine and a half, and 12, and don't think I'm 5'11", and I've been the same height since I was 14, and my mother was 5'2". Anyway, that leads to a different story. But my grandson used to say to me, granddaddy, would you do that thing with my ear that makes my ear go away? And I've always tripped to the urgent care center, the pediatrician, et cetera, et cetera. And if you haven't experienced treating kids, you're doing something. And parent, when they bring in their kid, they want you to do something. And they get upset if you don't give them a prescription. And we all know that most otitis media is viral in its etiology. So you don't want to give, in that case, an antibiotic. But a lot of us succumb to that situation, et cetera. But if you can do this nice, simple treatment, and Jeffrey, come over, and I'll do it. It's real simple. And you can even do it yourself. And I'll show you that in a minute. You just simply have the head cradled, and you go with a V-notch, put it underneath the ear, and you now then make the ear go back and forth and back and forth, and go backwards and forwards. So you can do it for yourself, too, which I'll show you again in a minute to help try to loosen that. Every little kid coming into the ER is osteobated. They're trying to manipulate their ear to get it to pop and make the pain go away. Okay? Osteopathy is something that evolved in the 1800s. We didn't have lots of good drugs then. There was no FDA. There were no LD50s or any other kinds of things, et cetera. Yeah, we did do that. Hey, listen, I'm old enough, and you may be also, Al, where when you got a cut or something that were a camp, they put mercurochrome on you. That's right, mercurochrome. All right? So they put mercury on us. I even had a picture of myself three weeks pre-partum. So you stick the x-ray up, and I show my residents and my medical students. I said, what's that? And they're like, oh, what is that thing there? And they're looking at, is that a tumor there where it's got like a spine fracture? I said, no, that's me three weeks pre-partum. That's my foot. That's my spine. That's my head. I said, you see what's wrong with me and people my age is that we were irradiated in utero. There was no such thing as an ultrasound. As a matter of fact, shoe stores, Buster Brown, they used to have the little box, and you stood on the box and wiggled your toes. That was a fluoroscope, unleaded, no lead, no shield. And the guys, the shoe salesmen and their ties, they were all getting irradiated eight hours a day, 40 hours a week. A large, large number of them died of cancer, obviously. So again, I showed you turn toward the physician. Physician could typically be seated and you prop them up again with your hand under their head, and then put your other hand up by the ear and cause the drainage. And it was real easy when my grandson was three. It's still easy when he's 12 if I need to do that for him, but he's a bigger pain in the neck now at 12 than he was at three. And just remember, grandchildren are your reward for having not killed your teenagers. I described this, and you continue this again, 30 to seconds to half a minute to two minutes is sufficient to do this. Okay, and there's your auricular drainage aspect. Again, circular motion, just going around, go one direction and then the other. All right. Now, the mandibular drainage technique, the gallbladder technique will help you again. Chronic serous otitis media, milder cases, and in barotitis, ding, ding, ding, ding, ding. Okay. Can you do this as the only thing? Yes, it very often will work, particularly if you're doing self-treatment. Okay. So don't do this. It's a relative contraindication if the person has TMJ dysfunction or severe otitis media. Okay. But Jeffrey, come on back up. And what you do is you have the patient open their mouth slightly. There you go. And you put your hand behind their jaw, the fingers behind the jaw, and the heel of your hand on their mandible, and you bring it across. Now, this is assuming that his right ear is the problem, that would be the right way. Otherwise, you got to do it on the left side there. All right. And again, I showed you a place. It takes longer with the verbiage than it takes to demonstrate. And you draw the forward at the temporal mandibular joint and deviate the jaw laterally away from the side that's being treated. And again, 30 seconds to two minutes, there's a picture of what I was doing to Jeffrey. Now, when prevention and in-flight techniques are not effective, what can you do self-OMT? Here's my way of doing this, and it's worked for me. And that is do the mandibular drainage first. Okay. Then do the auricular drainage techniques. Again, I'm assuming I'm treating my left ear here. Doing the cervical chain drainage, and this gets a little harder. Sometimes you got to go across and bring it on down, and what have you, and the anterior arches. You cannot effectively do a Sipson's fascia or an inlet technique on yourself. Okay. But that doesn't really work well. Yeah. For these procedures, how long before you notice anything? Most of the time, you're going to notice it within minutes, moments. So this is really, really effective as far as I found in my practices and then doing things like that. And when I've had to cheat and do it all myself, because I was stupid and chose to fly with a head cold, and even though I wasn't going up, let's face it, in a Cessna, you're not doing very much. And when I was flying things that went much faster, it was before I was 40, because 40 is when I applied to medical school. So yeah, guys, I'm old. No, both sides. You take your index finger and your thumb, and you form a U, and your anterior, and you move them back and forth, up and down the whole length, and you'll feel them. And then as it loosens up, you're good. You're very welcome. So that was that. Are there any other questions just before we get started on this? Okay, let me go ahead and I'm again going to dedicate, I'm dedicating this to memory of my lifelong friend. He's a high school classmate of mine, but Mitch and I knew each other from a summer program that we went to an art camp together at like fourth grade. And he's a Desert Storm veteran, was retired from the Army Reserve and passed due to mantle cell lymphoma. So I miss him all the time. And that's where we are there. Now, questions? Is there any kind of network we can go to to find DOs that do on-site project manipulation? Okay. Yes. The question that was asked here was, is there any kind of a network that we can go to to find the DOs that actually do manipulation? Okay. And the answer is yes. Your best source of that is to go to the academy, the AAO, the American Academy of Osteopathy, and either contact them by phone or look on site and find a doctor in that order to do that. The other thing is that the AOA has a site under find a doctor, and I believe one of the specialties that they list is OMM or OMT or neuromusculoskeletal medicine too. So that might also help. Yeah, I'm boarded in three boards, NMM, OMM, and that's one board, General Preventive Medicine and Public Health, and OCMED, so. There's no questions in the chat. No question in the chat, so they either took off, so I know. Well, they totally understood everything I did, which is probable. All right. Hey, ladies and gentlemen, if you have any questions, I'm here through the weekend.

osteopathic manipulative medicine

barotitis

airplane ear

pressure changes

OMM techniques

Eustachian tube

preventative measures