History: An upset father presented to my office on 4-30-99, with his 9 year old son, who has been having chronic ear infections, Patient's father states that his son has had ear infections for the past 6 years and are progressively getting worse- He states that his son has been on and off antibiotics, Amoxycillin and Biaxin on a regular basis at least every 6 weeks for the past 6 years. It is noted that this patient has had prior surgery when tubes were put in his ears, approximately 5 years ago. The tube in his left ear recently fell out. Upon the patient's last visit to his EENT, another surgery to remove the remaining tube and reinsert new tubes in both ears was suggested. Additionally it was suggested to remove his tonsils and adenoids at that time. At exam, the patient was scheduled to have this surgery in 3 weeks. History of the mother's pregnancy and birth were unobtainable due to a divorce and father did not recollect much about the delivery. It is noted that this patient is a heavy dairy consumer. At this time, I have discussed with the father the benefits of chiropractic care for his child and he has agreed to postpone the surgery for 6 weeks and give chiropractic a chance.
Examination: An in depth chiropractic examination was performed, which revealed bilateral effusion and scar tissue in both ears. Patient has submandibular glandular swelling as well as tonsillitis and redness of the throat. There is also swelling of the posterior cervical musculature, with inflammation bilaterally at the splenius capitus and splenius cervicus. Range of motion to the cervical spine is within normal limits. There is a positive foraminal compression test. Static and motion palpation examination reveals evidence of C2 and C6 subluxation complexes. Postural analysis showed a left head tilt with a high right shoulder.
Care Plan: Recommendations were made for adjustments 3 times a week for 6 weeks at which time he will be reevaluated and a new care plan will be determined. Nutritional recommendations were made. I have recommended discontinuing the use of all dairy products at this point. Due to the heavy antibiotic usage, I have also advised this patient to take acidopholus and lactovasic acid to help replenish the normal flora in the gastrointestinal tract.
Patient's Progress: The patient has shown vast signs of improvement after his second adjustment. His father stated that his son is much more alert, is concentrating better in school. The teachers have actually noted the improvement the last 2 days. The father also states that his son has not complained about his ears bothering him since the first adjustment. It is also noted that his throat pain had begun to clear up after his second visit. At the end of the 6-week program, the patient was reevaluated. There was no more effusion in either ear. Rhinnes and Weber test were within normal limits. Tonsils and adenoids were back to their normal size. The father stated that surgery was no longer indicated by the EENT. The patient was advised to continue care plan of 1 time a week for the next 6 weeks to and will continue to be monitored. After that time, he may be put on a wellness care plan of 1 time a month for chiropractic evaluations.
Discussion: To this date is has been approximately 5 months since the patient's first visit to our office. He has had no bouts of ear infections up to this time, no sore throats, no colds, no flu's and has been on no medication. He is back on dairy, however his consumption is much less than previously consumed. This patient is now back to a normal lifestyle and patient's father has also reported that his grades are up since he started his chiropractic care. This patient will continue a once a month chiropractic evaluation program and since his son has done so well, the father has decided to have his other son put under chiropractic care because of a learning disability due to a hearing problem. Harley Bofshever D.C. International Chiropractic Pediatric Association Newsletter Nov-Dec, 1999.