Scenario 1: You are a first-year pediatric resident working in an after-hours clinic. Your first case of the day is a 4-year-old boy, Jeremiah, who began complaining about muffled hearing the week before. Jeremiah had never shown any sign of hearing loss prior to this time and previous well-child visits to the doctor were unremarkable. Upon examination, you note a small, soft object lodged in Jeremiah's left ear. After some manipulation, you are able to remove a small foam ball from Jeremiah's ear and restore his hearing. You explain that Jeremiah was experiencing conductive hearing loss in his left ear due to the foreign object blocking the auditory canal. Future hearing problems would not be an issue as long as the canal remains clear.
1) Explain to Jeremiah's mother, in detail, the step in the hearing process that was affected by the presence of the foam ball in Jeremiah's ear. Using proper anatomical terms, be sure to explain what wasn't working and why.

Scenario 2:
Your next case is Billy, a two-and-a-half-year-old boy. His parents ask for an antibiotic prescription right away. Billy’s mom is sure that he has an ear infection because every time he has had these symptoms, he was diagnosed with an ear infection. Billy’s parents tell you that he is complaining of right ear pain, but he has not had any ear discharge. His symptoms started yesterday afternoon, and this morning his temperature was about 99.5oF. Last week, Billy suffered from a mild cold that he caught at daycare. He recovered from this ailment and is otherwise healthy. On otoscopic examination, you see a bulging and right tympanic membrane. His left tympanic membrane is normal. As his mother suggested, Billy is most likely suffering from acute otitis media and you prescribe Amoxicillin (first-line antibiotics) to treat the condition. Due to Billy's repeated ear infections, you refer him to an ENT for further care.
2. Using correct anatomical terminology, explain to Billy's parents what is causing his pain and bulging tympanic membrane. Why did this condition develop?

3. Why is it important to treat acute otitis media? Describe the dangers of leaving the condition untreated.

4. The ENT recommends the insertion of ear tubes due to Billy's persistent ear infections. Why is this procedure recommended in Billy's case? Be sure to use proper anatomic terms in your explanation.

Scenario 3
Later that day, you meet with a 62-year-old man, Jose, whose wife insisted that he come to the clinic because he has had progressive hearing loss in both ears. After a thorough examination, you determine that Jose has sensineural hearing loss due to his age. You refer him to an audiologist and explain that the doctor will most likely prescribe hearing aids for this type of hearing loss.
5. Jose is resistant to this idea and asks how hearing aids work. Explain, in detail, to Jose which step in which his hearing is impaired (using proper anatomical terminology) and why a hearing aid will help him hear better.

synovial joints are characterized by the presence of a joint cavity. the walls of this space are formed by the articular capsule, a fibrous connective tissue structure that is attached to each bone just outside the area of the bone’s articulating surface. the bones of the joint articulate with each other within the joint cavity.

friction between the bones at a synovial joint is prevented by the presence of the articular cartilage, a thin layer of hyaline cartilage that covers the entire articulating surface of each bone. however, unlike at a cartilaginous joint, the articular cartilages of each bone are not continuous with each other. instead, the articular cartilage acts like a teflon® coating over the bone surface, allowing the articulating bones to move smoothly against each other without damaging the underlying bone tissue. lining the inner surface of the articular capsule is a thin synovial membrane. the cells of this membrane secrete synovial fluid (synovia = “a thick fluid”), a thick, slimy fluid that provides lubrication to further reduce friction between the bones of the joint. this fluid also provides nourishment to the articular cartilage, which does not contain blood vessels. the ability of the bones to move smoothly against each other within the joint cavity, and the freedom of joint movement this provides, means that each synovial joint is functionally classified as a diarthrosis.

outside of their articulating surfaces, the bones are connected together by ligaments, which are strong bands of fibrous connective tissue. these strengthen and support the joint by anchoring the bones together and preventing their separation. ligaments allow for normal movements at a joint, but limit the range of these motions, thus preventing excessive or abnormal joint movements. ligaments are classified based on their relationship to the fibrous articular capsule. an extrinsic ligament is located outside of the articular capsule, an intrinsic ligament is fused to or incorporated into the wall of the articular capsule, and an intracapsular ligament is located inside of the articular capsule.

at many synovial joints, additional support is provided by the muscles and their tendons that act across the joint. a tendon is the dense connective tissue structure that attaches a muscle to bone. as forces acting on a joint increase, the body will automatically increase the overall strength of contraction of the muscles crossing that joint, thus allowing the muscle and its tendon to serve as a “dynamic ligament” to resist forces and support the joint. this type of indirect support by muscles is very important at the shoulder joint, for example, where the ligaments are relatively weak.

additional structures associated with synovial joints

a few synovial joints of the body have a fibrocartilage structure located between the articulating bones. this is called an articular disc, which is generally small and oval-shaped, or a meniscus, which is larger and c-shaped. these structures can serve several functions, depending on the specific joint. in some places, an articular disc may act to strongly unite the bones of the joint to each other. examples of this include the articular discs found at the sternoclavicular joint or between the distal ends of the radius and ulna bones. at other synovial joints, the disc can provide shock absorption and cushioning between the bones, which is the function of each meniscus within the knee joint. finally, an articular disc can serve to smooth the movements between the articulating bones, as seen at the temporomandibular joint. some synovial joints also have a fat pad, which can serve as a cushion between the bones.

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