The patient was seen by the ENT physician. The preceptor asked if she and the student may observe.  The ENT physician looked at the right ear, then put the child on the exam table lying down and removed debris from the ear canal. The ENT asked if cotton balls or q-tips had been used on the patient.  The mother reported that at one time cotton balls had been used to help antibiotic drops stay in the ear canal.  The ENT reported that cotton fibers were mixed with debris, which looked like pussy drainage from the middle ear that had accumulated and dried out. A perforation of the tympanic membrane could be seen once the ear canal was free of drainage. The ENT suctioned out debris from the middle ear and reported to the boy’s mother that there were “adhesions” that resulted from the longstanding problems in the right ear.  He went on to describe what that meant and what treatment would be needed.

The mother expressed considerable guilt; she said her “mother’s intuition” that she should have insisted on her son seeing an ENT much sooner.  The ENT side-stepped the issue of whether delay in treatment caused the problem to become worse. Instead he focused on reassuring the mother that it was unlikely there would be any permanent hearing loss.

• What are adhesions?
• How are they treated?
• Do you suspect that more prompt treatment of the middle ear problems could have prevented this complication?

The patient was retested after the removal of the debris. The audiogram is shown below.

The original air-conduction thresholds are retained for illustrative purposes.  The new air-conduction thresholds are shown; the other thresholds were not repeated.

• Describe the type and severity of the loss based on these new, masked thresholds for the right ear.
• Would this be described as a “maximal conductive loss”?