Neck Pain and Cervical Spine Instability-Induced Chronic Sinusitis and Eustachian Tube Dysfunction

Ross Hauser, MD

I am going to begin this article with a case history seen at our center and then we will discuss the research that shows a connection between cervical spine instability and neck pain leading to your problems of chronic sinusitis and various other conditions you may suffer from including Eustachian tube dysfunction.

As I have stated many times in the articles of our website, people we see rarely suffer from one problem or condition by itself. We see people who have chronic sinusitis as one condition among many. We see people who have Eustachian tube dysfunction as one condition among many. These symptoms can include tinnitus, ear fullness, vertigo, vision problems, facial pain, and numbness feeling. What many people have in common and the one constant condition they suffer from is neck pain.

A 25-year-old college student with chronic sinusitis and Eustachian tube dysfunction

A 25-year-old college student became a patient at Caring Medical. He suffered from a myriad of symptoms including chronic sinusitis. As with many 25-year-old men he engaged in sports, some high contact sports. He also worked out, trained, and ran. He also told us about the many high-speed impacts he had with other players during games. He reported a number of hits to the head. As his symptoms progressed his activity levels fell to a now “couch potato,” status.

He is a nose breather

After one particular game where he was involved in a high impact collision, our patient started to get popping sounds and a sensation of grinding in his neck. After the collision, he felt as if his nose was all plugged up. This presented a problem for him as he stated he was always a nose breather. As this symptom worsened, he stated he would spend 15-30 minutes every morning blowing his nose and using other decongest aids and techniques so he could breathe out of it.

Even when he was successful at this, this would only allow him to breathe out of his nose for a few minutes, then it would get stopped up again. He described it as having a really bad cold or flu all the time. With the stopped-up nose came ear fullness, hearing loss, tinnitus, and dizziness. His ears popped constantly, like balloons. He noticed the symptoms were worse when he looked down at his phone or the ground.

He saw many doctors, including ENTs, allergists, primary care physicians, emergency room physicians, a gastroenterologist, a cardiologist, and neurologists. They all said he had allergies and prescribed different types and variant strength decongestants, steroids, antihistamines, and other drugs to no prevail. He was also prescribed anti-anxiety medications.

Nothing helped, and worse, over the next six months, the symptoms were getting worse.


A clue from a deviated uvula

Why then were his anti-inflammatories not effective? Why were his anti-histamines not effective?

Again, as we typically see, this patient had various conditions and symptoms. Already mentioned above were trips to a gastroenterologist to track down digestive problems, a cardiologist to rule out heart problems, and neurologists to determine if neurological deficits and problems were at play here. As these other possible causes were being ruled out, what could be left? For some people, it is cervical spine instability and compressive problems in the neck. Nerve impingement can be going on.

When this person came into our center, it was after a screening process to determine if cervical spine instability could be realistically thought of as a cause of his problems. Once we suspected cervical spine instability as the underlying cause of his problems, we asked about other cervical instability symptoms including headaches, visual changes, neck/head, and scalp pain, he noted he had all of them. In fact, his neck was causing him a lot of pain and discomfort, enough so that he had sought out chiropractic care. Of which he did say that he did find relief, but only on a temporary basis.

A possible clue: A deviated uvula. What is this?

Upon his initial examination, we noted that he had a deviated uvula sitting to the left of where it should be. This typically signals right side vagus nerve injury and low vagal tone which correlated with his right side tinnitus from Eustachian tube dysfunction being worse than left. His digital motion x-ray showed a loss of the cervical curve (he had military curve), forward atlas (atlas anterior subluxation), and significant C1-C2 (atlantoaxial) instability.

What does all this mean?

Let’s stop the case history here so we can go deeper into the problems discovered during our examination and a better understanding of what is happening. We will also have some specialists come in, in the form of research papers that will help you understand what we saw in this patient’s first examination.

We mentioned:

  1. A deviated uvula
  2. Low vagal tone or vagus nerve injury. A connection to the trigeminal will also be made.
  3. A loss of the natural cervical spine curve.

Now let’s explore what is happening here starting with the deviated uvula.

1. A deviated uvula: In this video, Dr. Hauser explains what a deviated uvula can mean in patients with “neurologic-type” symptoms.

There are various clues that the vagus nerve is involved in the different and complex neurological, cardiac, and gastrointestinal problems some people have. One of the simplest ways to send us down the path of vagus nerve function is to simply look down the throat of the patient and see if the uvula (the small finger-like tissue that hangs at the back of the soft palate) deviates to one side, we call that a deviated uvula and a deviated uvula is one of the biggest clues that the vagus nerve is not functioning correctly.

We know, you may be saying to yourself, “I had all these tests, my doctors can’t find anything, how can looking down my throat tell me something the tests did not?”

This is where we call in the specialists, the medical research papers.

When it comes to strange symptoms, doctors often report cases that “stumped” them. By reporting these cases it is hoped that this will help those health care providers after they see these cases and maybe figure out something beneficial for future patients who may have similar symptoms.

What we will focus on here is a report of a uvula deviation and how this may be a way to screen unresponsive or difficult to treat or understand neurological and digestive type symptoms.

Here is a case reported in the Journal of Child Neurology. (1) It is about a 7-year-old boy who displayed symptoms very similar to our patient. Here is that story:

EXPLANATORY NOTE: Look at what is happening here. The boy had a deviation of the uvula and a “curtain” movement of the posterior pharyngeal wall (the back of the throat). The curtain movement is an involuntary movement of the soft palate at the back of the throat. The muscles of the palate move up and down like a curtain rising and falling. This problem is also associated with clicking in the ears. Clicking in the ears is a symptom of Eustachian tube dysfunction.

So what these doctors pointed out was there was a case of asthmatic bronchitis, which turned into other symptoms, it affected the vagus and hypoglossal nerves.

This case is presented to show the interplay between an infection, in this case, asthmatic bronchitis and vagus nerve malfunction. How one can affect the other.

2. Low vagal tone or vagus nerve injury. A connection to the trigeminal will also be made.

The cervical spine and “cervicogenic otoocular syndrome.”

Next, we are going to visit the opinion of a paper presented in The International Tinnitus Journal. (2) Here the researchers sought to make a connection between cervical spine disorders and hearing problems that would eventually result in tinnitus and Ménière’s disease. Here are the summary learning points:

What is being suggested here? Simply that a functional disorder of the upper cervical spine can cause hearing problems.

A clue suggesting vagus nerve compression is the problem: Some people with a functional disorder of the upper cervical spine have problems related to vision

The people in the above study noted a problem of mydriasis (pupil dilation) on the side of the affected ear.

When the Vagus nerve is injured by compression caused by instability at C1-C2, this can cause vasospasms (narrowing of the arteries and reduction of blood flow). If these vasospasms impact the ophthalmic artery, the artery that supplies blood to the eye and eye area including the orbit – this can lead to some of the symptoms are patients describe to us such as darkening, black spots, or grayness in the vision of one eye.

In this image, vision problems caused by cervical spine instability is connected to Diminished ocular blood flow, Exaggerated pupillary hippus dilating, Hampered accommodation or human ocular accommodation mechanism or accommodation reflex, Increased intra-ocular pressure or elevated intraocular pressure, Limited pupillary constriction, Optic nerve damage

In this image, vision problems caused by cervical spine instability is connected to Diminished ocular blood flow, Exaggerated pupillary hippus dilating, hampered accommodation or human ocular accommodation mechanism or accommodation reflex, Increased intraocular pressure or elevated intraocular pressure, Limited pupillary constriction, Optic nerve damage. 

Clicking in the ears, eustachian tube dysfunction, and chronic sinusitis. They are all connected.

There can be many reasons you have clicking in your ears, there can be many reasons you have chronic sinusitis. There can be many reasons you have both. This article presents one possible answer to why you may have not responded to treatment. That answer is a connection to cervical spine instability and neck pain.

In your research of chronic sinusitis and eustachian tube dysfunction symptoms, you learned that eustachian tube dysfunction is when the eustachian tube that connects the throat to the ears gets clogged. When this happens you can have ear fullness, ear pain, and hearing difficulties associated with a clogged eustachian tube. You learned that this is more frequent in people with sinusitis, allergies, who smoke, and people who are obese.

What are we seeing in this image?

Proper Eustachian Tube function vs. dysfunction. In this illustration, the proper opening of the Eustachian Tube is shown to require the action of the tensor veli palatini and the levator veli palatini muscles innervated by the vagus and trigeminal nerves. When these muscles do not operate normally, fluid builds up in the middle ear potentially causing the problems of ear discomfort, ear fullness, pressure, pain, dizziness, and even partial or complete hearing loss.

Proper Eustachian Tube function vs. dysfunction. In this illustration the proper opening of the Eustachian Tube is shown to require the action of the tensor veli palatini and the levator veli palatini muscles innervated by the vagus and trigeminal nerves. When these muscles do not operate normally, fluid builds up in the middle ear potentially causing the problems of ear discomfort, ear fullness, pressure, pain, dizziness and even partial or complete hearing loss.

Rhinosinusitis / Sinusitis – is this a drainage problem caused by herniated discs?

Above I suggested the connection between cervical spinal instability and a patient’s Eustachian tube dysfunction and sinusitis. Let’s look at the sinusitis part of his problem and also connect that to cervical spine instability.

First, let’s look at a case study in the Journal of Manual and Manipulative Therapy. (3) It looks at possible sinus headaches and the development of rhinosinusitis and a connection to neck pain.

Here are the summary learning points:

In the research of your symptoms, you have probably uncovered various connections between your neck pain and your problems with chronic sinus infection, sinusitis, and rhinosinusitis. Here you learned that much like problems with Eustachian tube dysfunction, an inability of the Eustachian tube to drain, you may have a problem with sinus drainage.

Malalignment of C1-C2 can impact sinus drainage

We have many articles and research studies that point out the possible problems misalignment of the C1-C2 or Atlantoaxial instability can cause. As I have also pointed out, the clue to a patient’s problems may lie in the fact that they suffer from many symptoms simultaneously and not from one or two isolated symptoms.

In the story of the patient that we are covering in this article, we see that he had many symptoms. People we see with Atlantoaxial instability can also suffer from drainage problems of the sinus and associated nasal congestion, headaches, hearing problems and ear infections, vision problems, balance, vertigo, dizziness, and nausea among many symptoms. Often they suffer all at once.

When the cervical spine is involved in chronic ear or sinus infections, we suspect that the patient is having a drainage problem. The ear and sinus are not draining. One reason that they are not draining can be a bulging or herniated disc impinging on the cervical nerves in the C1-C2 region.

The start of the chase for the root cause of the problem. The connection between the vagus nerve and the trigeminal nerve and sinus drainage

The vagus nerve, as illustrated below, travels through the cervical spine. It travels especially close to the C1, C2, C3 vertebrae. Cervical spine instability in these regions can cause herniation or pinching of the vagus nerve, which can lead to a disruption of normal nerve communication between the vagus nerve and the trigeminal nerve and trigeminal ganglion. This disruption or herniation of the nerve can cause among the many symptoms of cluster headaches.

What are we seeing in this image?

The vagus nerve, as illustrated here, travels through the cervical spine. It travels especially close to the C1, C2, C3 vertebrae. Cervical spine instability in these regions can cause herniation or pinching of the vagus nerve, which can lead to a disruption of normal nerve communication between the vagus nerve and the trigeminal nerve and trigeminal ganglia. This disruption or herniation of the nerve can cause among the many symptoms of cluster headaches.

The vagus nerve, as illustrated here, travels through the cervical spine. It travels especially close to the C1, C2, C3 vertabrae. Cervical spine instability in this regions can cause herniation or pinching of the vagus nerve, which can lead to a disruption of normal nerve communication between the vagus nerve and the trigeminal nerve and trigeminal ganlia. This disruption or herniation of the nerve can cause among the many symptoms  cluster headaches.

In the context of this article, we will simply explore how cervical spine instability impacts the trigeminal nerve and how this impact can prevent your sinus from draining. A more complex understanding of the trigeminal nerve is found here: The evidence for Trigeminal Neuralgia non-surgical treatments.

The head and neck, as all parts of the body, live in complex relation. Compression of the cranial nerves including the vagus nerve and the trigeminal nerve can cause among many symptoms, a problem of sinus drainage.

Our bodies have a left side trigeminal nerve and a right side trigeminal nerve. The trigeminal nerve separates into three branches. The ophthalmic (V1), maxillary (V2), and mandibular (V3) nerves.

In regard to the sinus:

  • The ophthalmic nerve (V1) serves the eye and parts of the nasal cavity. Damage or dysfunction of this nerve can impact sinus function and vision. This is why people have these symptoms concurrently. This could include sinusitis. Sinusitis can occur when the nerve messages are getting distorted and signals for proper drainage of the sinus are not getting through. Note that a dysfunction of this branch can cause pupil dilation as cited above as well as many other vision problems. Pupil dilation is a tell-tale sign of cervical instability that can be causing sinusitis.
  • The maxillary nerve (V2) also serves parts of the nasal cavity and sinus as well as portions of the mouth. This is why sinus congestion and sinusitis can be reported by patients along with problems of the palate as noted in a study above. A deviated uvula can be a tell-tale sign of palate dysfunction and as stated above a clue of cervical instability causing sinusitis and Eustachian tube dysfunction.
  • The Vagus nerve serves the sinuses, the back of the throat (pharynx), and the larynx.

3. Restoring the natural curve of the spine and strengthening cervical spine ligaments – a possible treatment for Chronic Sinusitis and Eustachian Tube Dysfunction

Many patients we see when they come in for their first visit for issues of chronic pain and neurological symptoms, come in with an understanding that something is wrong with the curve of their neck and spine. This they learned through the many years of seeking treatments. This is why they also understand that the curvature of the spine is a complex problem

In the story of our patient in this article, we noted that he had a military curve. A loss of the natural cervical spine curve.

The curvatures of the neck

What are we seeing in this image?

In our practice, we see problems of cervical spine instability caused by damaged or weakened cervical spine ligaments. With ligament weakness or laxity, the cervical vertebrae move out of place and progress into problems of chronic pain and neurological symptoms by distorting the natural curve of the spine. This illustration demonstrates the progression from Lordotic to Military to Kyphotic to “S” shape curve.

In our practice we see problems of cervical spine instability caused by damaged or weakened cervical spine ligaments. With ligament weakness or laxity, the cervical vertebrae move out of place and progress into problems of chronic pain and neurological symptoms by distorting the natural curve of the spine. This illustration demonstrates the progression from Lordotic to Military to Kyphotic to "S" shape curve.

Repairing the ligaments and curve for a long-term fix

The goal of our treatment is to repair and strengthen the cervical ligaments and get your head back in alignment with the shoulders in a normal posture.

What are we seeing in this image?

In this illustration, we see the before and after of neck curve corrections. Ligament laxity or looseness or damage, whether the cause is from trauma, genetic as in cases of Ehlers-Danlos syndrome, ultimately causes a kyphotic force on the cervical spine, stretching the posterior ligament complex of the neck. As can be seen in the x-rays of this image, patients with a whiplash injury, Joint Hypermobility Syndrome, and Ehlers-Danlos syndrome can have their cervical curve restored with Prolotherapy Injections and the use of head and chest weights.

In this illustration we see the before an after of neck curve corrections. Ligament laxity or looseness or damage, whether the cause is from trauma, genetic as in cases of Ehlers-Danlos syndrome, ultimately causes a kyphotic force on the cervical spine, stretching the posterior ligament complex of the neck. As can be seen in the x-rays of this image, patients with a whiplash injury, Joint Hypermobility Syndrome, and Ehlers-Danlos syndrome can have their cervical curve restored with Prolotherapy Injections and the use of head and chest weights, documented below.

Treating Cervical Instability-Induced Chronic Sinusitis and Eustachian Tube Dysfunction with Cervical Curve Correction and Prolotherapy

Let’s now return to what happened to our patient. At the onset of this article I described that when this person came into our center, it was after a screening process to determine if cervical spine instability could be realistically thought of as a cause of his problems of chronic sinusitis and Eustachian tube dysfunction.

Once it was determined that his problems were coming from his neck we started Prolotherapy treatment and cervical spine curve correction.

  • The patient had a remarkable recovery as after four Prolotherapy and cervical curve correction treatments his chronic sinusitis was 90% gone, as well as noted and significant improvements in his other symptoms. He was able to 100% breathe out of his nose again and the horrible sounds in his ears, ear fullness, hearing impairment, tinnitus were almost entirely alleviated.
  • Follow up x-rays, digital motion x-rays showed significant improvement in his neck curve and cervical stability.
  • After some time, he had some tightness return in his neck. He went to a chiropractor and thought he was just going to get a massage or some other gentle technique. Instead, he received a high-velocity manipulation at the C1-C2 area. The chiropractor did rapid rotational movement and after that, he had a return of 30% of his overall symptoms but 50% of his chronic sinusitis, ear fullness (blocked Eustachian tube), hearing impairment and tinnitus returned.
  • He required three more Prolotherapy visits to alleviate these new symptoms.

Brief summary.

The sinuses of the head and face/nose are interesting in that they involve several cranial nerves (especially cranial nerve five (trigeminal) and 10 (vagus/parasympathetic) and the superior cervical sympathetic ganglion. In this particular patient, his loss of the cervical curve and anterior subluxation of the atlas would stretch neck structures such as the vagus nerve (whose primary ganglion (nodose)) sits right in front of it and on top of the cervical sympathetic ganglion which is in front of C2. The forward head carriage he had, evidenced by anterior subluxation of C1 (a common finding that they go together) again could inhibit vagus and/or cervical superior sympathetic ganglion flow, but note it could also just throw off the normal balance that occurs with the autonomic nervous
system, which occurred in his case.

Let’s also take a moment to specify that not all patients have results like these. There is nothing typical about these problems and treatments. The cases we see are very complex and that is why we carefully screen patients for their appropriate candidacy.

Treating cervical ligaments with Prolotherapy  – published research from Caring Medical

Prolotherapy is an injection technique that stimulates the repair of unstable, torn, or damaged ligaments. When the cervical ligaments are unstable, they allow for excessive movement of the vertebrae, which can stress tendons, atrophy muscles, pinch on nerves, such as the vagus nerve,  and cause other symptoms associated with cervical instability including problems of digestion among others.

In 2014, we published a comprehensive review of the problems related to weakened damaged cervical neck ligaments in The Open Orthopaedics Journal. (4) We are honored that this research has been used in at least 6 other medical research papers by different authors exploring our treatments and findings and cited, according to Google Scholar, in more than 40 articles.

In our clinical and research observations, we have documented that Prolotherapy can offer answers for sufferers of cervical instability, as it treats the problem at its source. Prolotherapy to the various structures of the neck eliminates the instability and the sympathetic symptoms without many of the short-term and long-term risks of cervical fusion. We concluded that in many cases of chronic neck pain, the cause may be underlying joint instability and capsular ligament laxity. Furthermore, we contend that the use of comprehensive Prolotherapy appears to be an effective treatment for chronic neck pain and cervical instability, especially when due to ligament laxity. The technique is safe and relatively non-invasive as well as efficacious in relieving chronic neck pain and its associated symptoms.

In this video, DMX displays Prolotherapy before and after treatments

  • In this video, we are using a Digital Motion X-Ray (DMX) to illustrate a complete resolution of a pinched nerve in the neck and accompanying symptoms of cervical radiculopathy.
  • A before digital motion x-ray at 0:11
  • At 0:18 the DMX reveals completely closed neural foramina and a partially closed neural foramina
  • At 0:34 DXM three months later after this patient had received two Prolotherapy treatments
  • At 0:46 the previously completely closed neural foramina are now opening more, releasing pressure on the nerve
  • At 1:00 another DMX two months later and after this patient had received four Prolotherapy treatments
  • At 1:14 the previously completely closed neural foramina are now opening normally during motion

How do I know if I’m a good candidate?

Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.

Please visit the Hauser Neck Center Patient Candidate Form

References

1 Zannolli R, Acquaviva A, D’Ambrosio A, Pucci L, Balestri P, Morgese G. Vagal and hypoglossal Bell’s palsy. Journal of child neurology. 2000 Feb;15(2):130-2. [Google Scholar]
2 Franz B, Altidis P, Altidis B, Collis-Brown G. The cervicogenic otoocular syndrome: a suspected forerunner of Ménière’s disease. International Tinnitus Journal. 1999;5(2):125-30. [Google Scholar]
3 Petersen SM, Jull GA, Learman KE. Self-reported sinus headaches are associated with neck pain and cervical musculoskeletal dysfunction: a preliminary observational case control study. Journal of Manual & Manipulative Therapy. 2019 Aug 8;27(4):245-52. [Google Scholar]
4 Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. The open orthopaedics journal. 2014;8:326. [Google Scholar]

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