Multiple AOM episodes as a young child. None for the past year.

Tympanogram flat on one side.

Describe your management of this patient.

This child has a retraction pocket. A pocket of this type may be seen in children with a history of recurrent AOM and long-term middle ear effusion. In this case, chronic obstruction of the Eustachian tube has resulted in long-standing negative pressure. When this occurs, the tympanic membrane may retract far enough to cause a persistent pocket. Note that the pocket extends up into the pars flaccida, superior to the lateral process. Pockets such as this may fill with debris, and eventually form a benign tumor called a cholesteatoma. Such tumors may cause significant damage to the structures of the middle ear, and are often associated with significant hearing loss.

Note the small "scar" or sclerotic area on the TM immediately inferior to the pocket. This is a thickening in the TM where a pressure equalizing tube was placed several years ago.

This child should be referred to the otorhinolaryngologist for a hearing test and clinical evaluation. The placement of a pressure equalizing tube will often ventilate the middle ear sufficiently to prevent further evolution of this problem.