A 5-year-old boy is brought to the doctor by his mother because she is concerned that he may be experiencing hearing loss. Over the past several weeks, he has been turning the volume of his favorite television program louder and has been sitting closer to the television set. He has reached all his developmental milestones and is up to date with his immunizations. When asked, the child states that he feels that his ears are always “plugged up.” His medical history includes recurrent episodes of acute otitis media. He is currently afebrile. On exam, his nasopharynx is clear, and he has no cervical lymphadenopathy. On otoscopic examination, his left tympanic membrane (TM) is immobile with an air-fluid level behind it and partial dependent opacification. It does not appear to be erythematous. A vibrating tuning fork placed in the middle of his forehead is appreciated as louder on the left side when compared to the right. The same tuning fork, when placed on the left mastoid bone, is appreciated as louder in comparison to when it is placed near the left external auditory meatus.