Nasal Specific Technique as Part of a Chiropractic Approach to Chronic Sinusitis and Sinus Headaches.

Objective: To demonstrate the use of nasal specific technique in conjunction with other chiropractic interventions in managing chronic head pain.
Clinic Features: A 41-yr-old woman was treated for chronic sinusitis and sinus headaches. She had suffered weight loss and pain over a 2-month period.
Intervention and Outcome: Chiropractic manipulation and soft tissue manipulation administered 2-6 times per month for approximately 1 yr had minimal long-term effect on the patient’s head pain. When additional interventions (nasal specific technique and light force cranial adjusting) were added to the treatment regimen, significant relief of symptoms was achieved after the nasal specific technique was performed. The duration of the relief increased with successive therapeutic sessions, with minimally persistent symptoms after 2 months of therapy.
Conclusion: The nasal specific technique,when used in conjunction with other therapies, may be useful in treating chronic sinus inflammation and pain. Further investigation is needed toidentify the usefulness of the nasal specific technique as an independent intervention, the use of the technique in other types of patients and presentations, and the mechanism of therapeutic benefit.
(J Manipulative Physiol Ther 1995; 18:38-41)
Key Indexing Terms: Chiropractic, Sinusitis, Headache, Facial Pain.

INTRODUCTION:
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The “nasal specific” technique has been in use in the Pacific Northwest for many decades. Janse et al. (1), in 1947, described a technique for distention of the nasal chamber by using a “carefully lubricated and sterile finger cot” attached to the detached cuff of a sphygmomanometer. The cot is inserted into the nasal chamber and inflated by squeezing the bulb of the folded sphygmomanometer cuff. They describe using a slow increase in bulb pressure that causes “a widening and distention of all the sinus openings” into the meatus. Janse advocated releasing the bulb and repeating the procedure several times. No indication or contraindications for the procedure were given in the text.

Finnell describes the nasal specific procedure for use decongesting the nares and treating sinusitis and certain types of asthma in his 1951 edition EENT manual (2) and again in his 1955 manual (3). He describes attaching a single finger cot to the bulb of a “blood pressure instrument” with its valve. He advocated attaching the cot to the bulb with a rubber band and inflating it to the size of a fist to check for leaks. The cot is deflated and wetted with cold water. Standing beside the patient with the head supported, the cot is introduced into the nose with a lubricated wooden applicator along the floor of the inferior meatus. When the cot is inserted as far as possible,

the wooden applicator is removed, the valve closed, and the nostrils squeezed closed. The cot is inflated with a quick pressure on the bulb, forcing the inflated cot into the throat. He de-scribes leaving the cot inflated for 1-2 min in the middle and lower meatus. A sharp instrument is kept handy for piercing the cot in the mouth, if necessary.

Chiropractor and naturopath J. Richard Stober is widely credited for refining and popularizing the technique in the Pacific Northwest. Stober’s technique is similar to Finnell’s except that two to five nested latex finger cots coated with water-soluble lubricant are used. The technique is applied in the following pattern: right lower meatus, left lower meatus, right middle meatus, left middle meatus, right upper meatus, left upper meatus, right lower meatus and left lower meatus; Stober would start on either side as clinical conditions warranted, but the alternation of sides and vertical order remained the same. The number of cots used varies depending on the desired force of exertion on the mucosa and facial bones; a larger number of nested cots requires a greater bulb pressure to inflate and thus exerts a greater pressure against the walls of the nasal cavity.

After the cots are tied onto the sphygmomanometer inflation bulb (preferably a trigger release model) with thread or other suitable media, the cots are lubricated with water soluble jelly and gently inserted into the desired meatus with the broken end of a flat toothpick. Care should be taken to avoid irritating the mucosal tissue with the toothpick. Once the nested cots have been fully inserted, the toothpick is removed; the patient inhales fully (to prevent aspiration of a cot frag-ment, should it break); the nares are squeezed closed to prevent passage of the cots anteriorly out the nares during inflation, and the bulb is squeezed or pumped until a sudden decrease in bulb pressure is felt as the cots expand posteriorly past the firmer facial and cranial bones into the softer tissues of the nasopharynx and soft palate. Once the change in bulb pressure is perceived, the cots are deflated quickly to minimize patient discomfort (Stober did not advocate inflating the cot into the mouth, nor sustaining inflation). The technique is repeated with the remaining meatus in the order described above. It is common for the patient to hear “cracking” or “popping” sounds within the skull during the technique. Occasionally, they can be perceived by the practitioner. Patients frequently describe the first treatment as uncomfortable or painful, similar in sensation to aspirating water into the nasal passage. Successive treatments are typically progressively more tolerable. Tenderness following the treatment along the median palatine suture or other facial sutures is common, persisting for a few hours or a few days.

Epistaxis can occur, but is not commonly long in duration nor large in volume. To avoid unnecessary trauma and prolonged epistaxis, the patient is advised to blow the nose gently into a tissue following the treatment, until the presence or absence of epistaxis is known. application

Practitioners are advised to be prepared for more severe epistaxis, and to avoid using the technique with patients on anticoagulant medications or with known hemorrhagic disorders. Caution should be taken in using the technique when histories of facial trauma exist, although anecdotal reports describe lasting pain relief when the technique is applied to patients with histories of facial fractures and deviated septums.

Berman (4) describes the therapeutic application of Stobers’ technique or use with headaches, temporomandibular joint (TMJ) dysfunction, chronic nasal and sinus congestion, and infection. He reports that patient response is often dramatic and long lasting. Berman also reported other improvements including “greater facial symmetry, less need for orthodontic intervention, fewer disorders of visual refraction, less earaches and ear infections, less mouth breathing, improved balance and coordination, fewer spinal complaints, and improved mental abilities.” Berman offers that correction of “skull dysfunction” is the mechanism by which the technique is effective. He admits that no proof of such claims exists other than anecdotal evidence, including his direct experience.

No articles appear available in the scientific literature that examine the efficacy of the nasal specific technique for treating any pathology. Searching for such literature uncovered one unpublished study by Nyiendo and Goldeen (5). Their study concluded that claims for improved vision and hearing following nasal specific treatment could neither be supported nor refuted. They did find, however, changes in craniofacial measurements that did not reach significance when compared to a control (sham-treated) group. They did not examine the use of the nasal specific technique for complaints of sinusitis and/or sinus headaches.

CASE REPORT:
A 41-yr-old woman presented to the Eastside Community Clinic, a satellite clinic of Western States Chiropractic Clinic, complaining of inexplicable weight loss, chronic constant pain over temporal region of the head (typically right sided), chronic pain and pressure sensations over her frontal and maxillary sinuses, and posterior neck and upper thoracic pain. The weight loss was 14 pounds over a period of 2 months. which occurred despite a reportedly large caloric intake. She reported no night sweats, fever, lymphadenopathy, changes in bowel or bladder habits, nor any decrease in appetite.

Her past history was significant for sexual, physical and emotional abuse, hepatitis B infection, and intravenous narcotic and alcohol addictions. Her memory of the abuse was unclear; she could not recall specifics of the injuries she suffered. She had been “clean and sober” for nearly 3 yr and her current partner is nonabusive and supportive.

Her past treatment included a year of chiropractic manipulative therapy and soft tissue manipulation that gave her some relief from her spinal discomfort, but did not give her significant or long-lasting relief. She had also been prescribed butalbital (a barbiturate) and Beconase (beclomethasone, a steroid), both of which she takes on a regular basis.

On examination, she appeared subdued and moved her head slowly and cautiously. Her voice tone suggested nasal and/or sinus congestion. Her height was 5’6″. Her weight was 124 pounds, down from 138 less than 2 months prior. Numerous segmental motion restrictions (6) were found throughout her spine, especially in her upper cervical vertebrae. Her suboccipital, levator scapula, rhomboid, and upper trapezius muscles were taut and tender bilaterally; numerous trigger points (7) were found throughout these muscles. On palpation, motion of the cranial and facial bones was restricted and abnormal (8).

A complete blood count (CBC), urinalysis (UA) and nonfasting serum chemistry panel were performed. The CBC and UA were unremarkable. The serum chemistry panel revealed slightly decreased glucose, slightly elevated cholesterol and elevated liver enzymes.

She was diagnosed with chronic sinusitis and sinus headaches with concomitant cervical and upper thoracic myofascitis. No underlying pathology responsible for the weight loss was uncovered. The elevated liver enzymes were attributable to a past and current history of drug use, past alcohol use and past history of hepatitis B. Treatment consisted of the nasal specific procedure (earlier with two cots, then later with three cots], chiropractic manipulative therapy (9), ischemic pressure to trigger points (10), and light force cranial manipulation (as described by Upledger and Vredevoogd (11) and others]. Treatment was given 15 times over a period of 2 months. The nasal specific procedure was included for 10 of those treatments.

Over the 2 months of treatment, her headaches reduced significantly in intensity and frequency. During the second month of treatment, she had only one slight headache. Typically, her headaches would resolve immediately following the nasal specific therapy. She also reported increased amounts ofpost-nasal drainage immediately following the treatment and continuing for several days post-treatment, increased visual acuity, increased sense of smell, the ability to taste her nasal medication (Beconase) in the back of her mouth, increased sensitivity to her medications, and an increased ease of sleep and breathing.

As an apparent side effect of the nasal specific therapy, she reported a feeling of dissociation immediately following the treatment, and occasional strong emotional reactions starting a few minutes after the treatment and lasting from 1-10 hr. She was not uncomfortable with these side effects, and over the 2 months expressed tremendous gratitude for relief of her headaches. Her affect appeared to change from subdued to cheerful, bubbly and positive over the 2 months. She also reported an increased ability to handle stress successfully. As she expressed it, “I’m learning to live life without headaches”.

DISCUSSION:
This case illustrates treatment of chronic sinusitis and sinus headaches by means of nasal specific technique, chiropractic manipulative therapy, trigger point therapy and light force cranial manipulation. Numerous threats to validation exist due to the design of the study (single subject, subjective evaluation). Generalization to other patients, doctors and variations in technique is very limited. The short follow-up period also threatens validity.

Since the nasal specific procedure was used in conjunction with other techniques, the effectiveness of the nasal specific technique is not completely known. However, as noted above, the patient had received a year of chiropractic manipulative therapy and soft tissue manipulation without significant longterm change in her head pain before the addition of the nasal specific technique and light force cranial manipulation. In addition, the patient consistently reported an immediate cessation of head pain following inflation of the cots. Given the immediate pain relief following the nasal specific procedure (and not following the other interventions or during insertion of the cots), a hypothesis relating the effectiveness of cot inflation during the nasal specific technique in treating sinus headaches can be formed.

Numerous theories could be used to explain the benefits of the nasal specific technique for chronic sinusitis. One such explanation may be the direct elimination of mucous from the nasal cavity by the force of the inflated cot, thus reducing pressure and pain and allowing increased sinus and nasal drainage. It is also possible that pressure against the thin, slightly pliable bones surrounding the sinuses allows equalization of pressure in the sinus to that of the atmosphere. Scuba divers report immediate cessation of sinus and middle ear pain with equalization of pressure in the sinuses and middle ear with the atmosphere; the nasal specific technique could cause a similar equalization, thus explaining the immediate cessation of sinus pain following application.It is also possible that a neural reflex exists by which the nasal specific technique causes mucous thinning and/or altered discharge. Mechanically compressing edematous tissues may result in a vascular response that leads to normalization of function. This sort of neural or vascular response may be responsible for some of the after-effects of the technique: increased sinus drainage, mucous thinning, longer-term pain relief, etc.

Another theory might relate the restoration of “normal” cranial motion with enhanced physiological functioning. Upledger relates several cranial dysfunctions to chronic sinusitis. Magoun (12) suggests that alterations in cranial motion contribute to sinusitis. Berman (4), Frymann (13) and Sutherland (14) also have contributed to the theory that abnormal cranial motion and function are related to pathophysiology. It is possible that the therapeutic effect of the nasal specific technique is created, in part, via the correction of alterations in cranial motion which may predispose a patient to chronic sinus infec-tion. The patient often reports hearing “popping” and/or “clicking” within the head during the procedure. It has been suggested that these noises may be due to the movement of cranial bones relative to each other and possibly small “cavitations” with the sutures. If alterations in cranial bone position or movement and/or pathophysiological sutural relationships cause head pain, then the immediate cessation of head pain following the technique may be due to induction of movement between cranial bones, similar to the reduction of spinal pain following manipulation, as suggested by Berman.

CONCLUSION:
Further study is necessary to determine the validity of the nasal specific technique for use in treating patients with chronic sinusitis and sinus headaches. Objectification of patients’ pain level, the use of controls (untreated or shamtreated), and a longer follow-up period could increase validity. Use of the nasal specific as sole treatment may also help isolate its effects from that of the combination of therapies used in this case study. Research into the therapeutic mechanism of the nasal specific procedure is also lacking.

ACKNOWLEDGMENTS:
The principal author wishes to thank Robert Homa-Godreau, D.C. for introducing him to the nasal specific technique. Special thanks are also given to Lester Lamm, D.C. and Steve Oliver, D.C., for continuing instruction in the nasal specific technique at Western States Chiropractic College.

REFERENCES:
1. Janse 1, Houser RH. Wells BF. Chiropractic principles and technic. Chicago: National College of Chiropractic, 1947: 623.
2. Finnel FL. Constructive chiropractic and endonasal-aural and allied office techniques for eye-car-nose and throat. lst ed. Portland, OR: Ryder Printing Co., 1950: 145-9.
3. Finnell FL. Constructive chiropractic and endonasal-aural and allied office techniques for eye-ear-nose and throat. 3rd ed. Portland, OR: Ryder Printing Co.. 1955: 149-50.
4. Berman S. Skull dysfunction. Cranio 1991: 9:268-79,
5. Nyiendo J. Goldeen A. A study of the effects of the nasal specific technique on vision, hearing, and dental/craniofacial measurements. Western States Chiropractic College Library, 1981.
6. Gatterman MI, et al. Chiropractic management of spine related disorders. Baltimore: Williams and Wilkins, 1990; 75-7.
7. Travell JG, Simons DG. Myofascial pain and dysfunction. Baltimore: Williams and Wilkins, 1983; 1:59-62.
8. Magoun HI. Glossary of terms relating to osteopathy in the cranial field. Denver:’ Sutherland Cranial Teaching Foundation, 1966.
9. Gatterman MI. Chiropractic management of spine related disorders. Baltimore: Williams and Wilkins, 1990: 118-23, 1428,187-99,223-30.
10. Travell JG, Simons DG. Myofascial pain and dysfunction. Bal-timore: Williams and Wilkins, 1983; 1:86.
11. Upledger JE, Vredevoogd JD. Craniosacral therapy. Seattle: Eastland Press, 1983.
12. Magoun HI. Osteopathy in the cranial field. Kirksville, MO: Journal Printing Company, 1966: 289-91.
13. Frymann VM. A study of the rhythmic motions of the living cranium. JAOA 1970: 928-45.
14. Sutherland WG. The cranial bowl. Free Press Company, 1948.

Nasal Specific Technique as Part of a Chiropractic Approach to Chronic Sinusitis and Sinus Headaches.

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