POTENTIAL BENEFITS:
1. Immediate improvement of hearing.

2. Subsequent improvement of speech.

3. Reduction in the number of subsequent ear infections.

4. Shorter duration of an infection should one occur.

5. Prevention of tympanic membrane and ossicular bone degeneration from chronic ear infections.

6. Reduction in amount of antibiotics administered to prevent resistant organisms.

7. Adenoidectomy removes tissue obstructing the eustachian tube to permit normal ventilation of the middle ear space.

POSSIBLE ADVERSE EFFECTS:
Known potential adverse effects include:

1. Ventilation tube may become occluded and cease to function properly.

2. Early extrusion of the ventilation tube may occur.

3. Infection from water contaminants entering through the tube may occur.

4. Persistent perforation may occur which may require a grafting procedure to close.

5. Patient sensitivity to certain materials may result in tissue irritation.

6. Bleeding is a potential risk only if adenoidectomy is performed. Rarely, does it require any additional therapy.

I/We have been given an opportunity to ask questions about my condition, alternate forms of treatment, risks of nontreatment, the procedure to be used, and I/we have sufficient information to give this informed consent.

I/We certify this form has been fully explained to me/us, and I/we understand its contents. I/We understand every effort will be made to provide a positive outcome, but there are no guarantees.

_______________________________ ________________________________
Patient / Legal Guardian Witness
Date:__________________________
Time:___________________________