Treating the maxilla for lateral line issues, migraines and sinus problems
When it comes to the body carrying out a protective compensatory strategy, little else beats out the priority that is the brain and skull; afterall, you live there. This means even minor concussions or other head incidents and issues will typically dominate global protective mechanisms, even over substantial organ injuries, broken bones, and so on. Because of this, regardless of my patients symptom presentations and injury/surgical history, even if it’s something like knee pain post surgery, I want to assess the skull as the chances are outside of something like my patient having their foot run over by a car or such, there’s likely a precursor event that led to a lower quality motor pattern that made the injury easier to happen or more severe when it did. Such things very often include incidents of the skull.
So in short, we want to look up. Each skull bone has a line of tension it’s most likely to impact. I’ve spoken before at length about the impact of temporal bone dysfunction on the spiral/rotational line of myofascial tension and function. For at least half of my knee pain patients, their biggest driver is a contralateral temporal bone issue, whether it be vestibular, ear pressure event, hearing event, impact, and so on; if the temporal bone isn’t happy, the spiral line and everything in its route is subject to the same dis-ease.
Today I want to talk primarily about the maxillary and palatine bones, as well as the overall collection of sinuses, and to a more minor extent, the parietal bones. These are the final arbiters of our lateral line, and are both remarkably common and hit certain areas more than you’d expect, such as giving us a substantial vector to help patients who have sinus problems of any kind, as well as quadratus lumborum pain, among other situations. If your patient has laterally aligned issues, this is vital to consider and assess for relevance.
Symptom Presentation
We have a few reasons we may want to consider this source of dysfunction.
Before even considering symptoms, if we have a patient with a history of any injuries to the skull at all this is on the table, but especially parietal, frontal, nasal, maxilla or mandible bones, as well as any particularly notable dental procedures. Also remember that an injury doesn’t just mean a hospital visit; it can be as much as a patient tripping and hitting their jaw decently hard but not feeling much more than being sore for a few days, though severity certainly matters. We’re looking at things the brain would find threatening, not just things that need to heal. Impacts, even light, especially to the sinuses, are often quite substantial in this line of dysfunction. Bad sinus infections because of the pressure involved should also be considered as highly likely causes/contributors (in such cases, reference my article on manipulating the tensor veli palatini).
Symptomatically, the most direct and commonly subjectively experienced are lateral line myofascial/musculoskeletal issues, which is fully inclusive across the body in what might be affected (note it may only subjectively affect one area, but we can expect it to have impact more broadly even if it's sub-symptomatic, especially to the spine and hips) though most frequently quadratus lumborum (QL) function and relevant pain to the hip(s), lumbar, and distal rib(s).
Sinus problems. This is usually mostly drainage problems where it feels full, especially when lying down. Disruption to the bones of the sinuses can inhibit the function of the sinus circulatory veli, and our work can help normalize that. Sinus headaches are also relevant and unsurprising.
Migraines. Maxillary misalignment has a cascade of potential effects, given its role as being part of the foundation of the cranial vault and its connections to the trigeminal nerves. If I have a patient with migraines, this is one of the first things I want to look at for potential contributing factors. The first migraine patient I can recall treating had 5 concussions in highschool and had 2-3 migraines every week for the 8 years following, and part of the compensations from this was substantial maxillary palatine process misalignment…we’re talking 3-4 millimeters and with that difference being dropped left at the front, right at the back! We had to deal with the concussions, but adjusting this compensatory bit of fallout got rid of her migraines in one ~5 minute technique (the migraines never returned, we still keep in touch today). This wont be the case for all migraine sufferers but it’s seriously powerful work for the right patient.
Jaw dysfunctions. The above patient's jaw opened like a typewriter…meaning she’d start opening, had a HUGE lateral deviation (I’ve never seen one close to that big since) and then evened out to continue opening. This is a less common presentation but it's definitely a significant part of the apparatus.
In some severe cases we may get pressure on the eye(s), auditory dysfunctions including ear pressure, and even contributions to Tourette's (from severe irritation of cranial nerves largely from the temporomandibular joint area sending an enormous amount of sensory data back; think of it as a short circuit).
Bridging to our assessments below, I visually check out all of my new patients for maxillary misalignment, visible bony growth (called ‘torus palatinus’ and usually benign in an overall health and dental fashion, but is definitely relevant for us) at the joint or a very steep arch in the roof of the mouth. If I can see any of this, I'm going to thoroughly assess this topic.
Assessment
As we just mentioned, we want to visually inspect the roof of their mouth.
We are looking firstly to see if we can see the maxillary plates misaligned, though do note that quite often the patient has enough soft tissue over this surface that they may have a substantial misalignment and we won’t be able to see it, but if we can, we know we want to work on this.
If there is visible bony growth along the joint interface, it indicates a likely long term state of excessive/inappropriate forces that led to that bony growth, and lets us know this is a definite target.
Do they have a high arch in the angle of their upper mouth? We won’t be changing this in adults but it indicates problems in this area. For the very young we may be able to help this as a high maxillary oral arch will increase the chances of pain and problems through their life.
Even in the absence of infection, gently and slowly depressing the sinuses externally can be sore, but should not be! We should feel some gentle bony springiness, but it may instead feel hard and unyielding. These would indicate some sinus dysfunction even in the absence of subjective sinus symptoms, which we will want to approach.
I want to check for relevant muscle function in the lateral line, firstly any lateral muscle lines that they have symptoms in (supraspinatus, mid delt, lateral neck, obliques, glute medius/minimus), but always the QL’s, which are nearly universally strongly affected by sinus or maxillary dysfunction.
It's important to note here that muscular tone is not particularly informative as a muscle can be highly tight because it’s under active or because it’s over active. In severe cases…it may even be slack, so even the lack of tone is not very useful information. But function is always informative and actionable.
As such we’ll carry out a manual muscle test of each QL, with the right usually being horrible, the L being capable if either is, and our confirmation is the patient manually holding a sinus (usually left maxillary) with their hand or the roof of their mouth with their tongue (generally left side; don’t have them push it into the middle as this may give confusing results). If the QL function is improved by these stabilizing holds, the dysfunction is confirmed. You can also have them hold the opposite side of the oral maxilla with their tongue, which will usually make function worse and additionally confirm the relationship. If any contact makes things notably worse than the baseline test, it is still positive for an association we want to approach.Maxillary motility: does the motility of the maxilla feel stuck, especially in orientation down or towards each other and it’s not resolving with external maxillary work? This may be our issue.
If I see any of the above indicating issues in the area I want to glove up and manually assess the maxillary joint, though that means I’ll also be moving right into treatment afterwards. I’ll start just behind the teeth and sweep back and forth to feel for un-evenness between the two maxillary plates. Anything more than about a half a millimeter is significant, and in severe cases can be several millimeters (usually 0.5-1mm, but I’ve seen ~3mm here and there). I’ll check farther back as well briefly, as while our manipulations will be largely anterior, I want to see the full length. Do make sure as you sweep to get a sense of if the apparent disparity in position you feel is bony growth, or actual misalignment. This can be hard to discern if they have substantial bony growth that is highly uneven, especially as it may not be symmetrical. This mostly just takes time for familiarity and thinking through what you’re feeling.
Contraindications and Cautions
Sinus or other infections. Just wait until it’s over to mess with any of this.
In current recovery from an injury or surgery to the area, including concussion or other brain trauma, especially if there is a vascular component.
Pregnancy. We have enough potential to affect the pituitary that I would likely wait until after the pregnancy for this kind of substantial adjustment.
Treatment
First and foremost, sterilize and glove up, making sure to not touch anything with those gloves that you don’t mean to. Fully explain what you’re going to do with your patient before you start and make sure to get their comfortable consent, not hesitant agreement. Check in often and narrate as you go. This is one of the least invasive internal oral techniques I use, but we can never assume that the patient on the table in front of us has not had relavant traumas, or even just has hyperactive gag reflexes, and so we must take every caution we can to maintain patient comfort, even if just for ease and efficacy. Lastly, make sure you are following your state and board's requirements for training and consent (OR LMT’s requiring signed advanced consent with the ability to refuse or have someone with them, for example).
We start by standing above the head of the patient and slightly to opposite the side we’re going treat, and just as with the assessment mentioned above (which again, we'll generally just go from assessment to treatment but we'll pretend we're doing it separately for the description) placing a finger tip behind the front teeth, contacting the palatine process and swiping back and forth to feel for the alignment and disparity between the two sides. I will then check along that joint back to the palatine bones themselves to feel for alignment and any bony growth.
We are most likely to find the left palatine process elevated in relation to the right, but either can be raised and we can have a torsion with a given side high on the front, low on the back and the other being the opposite. Positional deviations besides left side elevated are often much more impactful when it comes to symptomatic presentation. Even if things feel generally even, they may be bilaterally descended so we’ll still want to work through them if our assessments indicate an issue here.
I will start my direct work by placing a finger pad on the very anterior palatine process of whichever bone is the most elevated, gently but firmly pulling anteriorly, laterally, and superiorly, almost feeling like I’m trying to torque the maxilla away from the skull, while my other palm stabilizes their head from around the lateral frontal area (gloved fingers NOT touching them to maintain a sterile contact surface for when we switch sides) of the side we’re working on. By starting with the elevated plate we can ‘create space’ for the more descended plate to rise to. I will work on a given side for about 20-30 seconds, feeling for how easily it moves with me or resists. I don’t feel a need to get all of the movement in one go; we want to move it a bit, get the other bone to rise a bit towards it, and continue back and forth.
After that initial 20-30 second movement, I will retract my hand and give them a moment to relax their jaw and move it around; there’s no need to have this feel like an extended dental procedure. Once they are ready I will repeat the same movement on the other maxilla. This one will likely not be as easy to lift on the first pass. We are trying more to coax the movement than to muscle it through, though this is also some of the most forceful work we do relative to other cranial techniques. When we teach this in person I carry this out in part on every student so they can feel the forces we’re working with.
I will go back and forth in this manner a few times as needed until I feel like we have both the amount of lift the skull is going to give us freely (noting again that it may start a bit resistant to the technique) and putting some extra time on the more descended side until the two bones are as even as I think is likely to happen that visit. This is to say we may not get things perfectly aligned in the first session and that’s perfectly fine, though I want to make the improvement in placement the body will allow.
For those with a stim based functional neurology skill set, I would carry out stims on my second bout of palatine process mobilization for each side, as well as during the active tensioning phases of any of the techniques noted below that we carry out. Stims on positive sinus pressure, especially with the maxillary sinuses, would be something I would plan to fit into the same session.
At this point we will give the patient as much of a break as they need (continuing to make sure our gloves have remained uncontaminated and we have not touched a surface with our fingers besides the patients mouth), and then I would want to carry out any other oral techniques I may want to implement, which will always include an internal maxillary motility check, likely sagittal maxillary decompression, as well as possibly viscerocranial joint manipulation and other intraoral nerves and soft tissues as relevant (such as the tensor veli palatini which I spoke about recently).
Following this I will deglove, re-sterilize my hands and then check overall cranial motility to help the skull adjust to the sizable change we just made via their maxilla (I like to think of the skull as a rubics cube where we cannot make an adjustment without affecting the whole so must address the other elements to achieve the balance we’re looking for, plus any other external targets (stim-based work on the external sinuses in a functional neurology skill sets and manual manipulation of the trigeminal nerve being the most common) and then recheck our measures from the start of this process.
With the general cranial piece, note that with previous trauma to the nasal/frontal/parietal bones or sinuses you’ll want to put particular focus on the motility and behavior of those bones after our intra-oral techniques. Also if we have time in class, I will go over a basic functional neurology technique for addressing some sinus traumas/dysfunctions but will be leaving that out of this specific article.
This maxillary manipulation may be a process we need to do two or maybe even three times, though anything past twice likely means a need for functional neurology focused work to previous traumas (head/sinus impacts primarily but it could perceivably be something else in the lateral line) or could be an inappropriate level/balance of firing in the ponto-medullary reticular formation (PMRF, a portion of the brain stim which has roles in contralateral coordination, some posture balance [ever notice almost everyone has the left side of their body elevated superiorly when they are supine? This would be the likely reason why], pain, and some other functions) which I would need to treat differently. But most of the time, the direct adjustment will still be one of the most powerful single techniques you’ll ever carry out when there’s need.