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Acute Otitis Media (AOM): An Endoscopic Findings at Its Early Stage

This image shows the appearance of the deeper ear canal and the eardrum at an early stage of acute otitis media.  An increase vascularity was noted at the umbo region and the vascular strip area superiorly.

Hyperaemia and inflamed auditory meatus with evolving middle ear effusion.

Established Acute Otitis Media: Pre-suppurative Stage

Severely inflamed osseous canal with bulging eardrum

and purulent middle ear fluid at its peak of inflammation.

 Inflamed and bulging eardrum with visible non-purulent effusion seen beyond it.

Acute Otitis Media: Suppurative Stage

 Figure shows a bulging and inflamed tympanic membrane with dual-layered appearance of middle ear fluid; the lower one represent formed mucopus whilst the upper layer by tenacious mucous.

 Acute otitis media with pus formed at lower quadrant of middle ear cavity 5 days after onset of right earache with concurrent upper respiratory tract infection.

Figure shows an increased vascularity of osseous canal with air-pus meniscus level behind the eardrum.

 Thick pus with clear demarcation of air-fluid level.


Pus formed within 24 hours of earache onset.  The superior segment of the eardrum is obviously inflamed and crescentic haemorrhage seen near its lower rim.

Figures show cumulated pus in the middle ear (beyond tympanic membrane) in the later stage of acute otitis media.  Increasing pus with ischaemic pressure necrosis complicates into eardrum rupture and discharging pus into the ear canal.

 Fully-formed pus with bulging tympanic membrane in a 3 year old boy.


Full-formed pus with very bulging tympanic membrane.

 Bulging of eardrum prior to rupture.


An extremely bulging superior segment of the eardrum with yellow tinge of pus seen.

A Recently Perforated Eardrum: A Sequel of AOM

Acute Otitis Media - Resolution of Infection with Small Central Perforation

Resolution of infection after completion of antibiotic therapy in a child who had acute otitis media two week earlier.  Please note smooth and healthy healing edges of the perforation.

Clues to Underlying Eardrum Perforation if Copious Ear Discharge Present

         Mucopurulent discharge                        Air bubbles within discharge

Acute Otitis Media: Responds to Treatment (Without Eardrum Perforation)

 Resolving acute otitis media evidenced by decreasing hyperaemia/vascularity.

Yellow-tinged (+) residual effusion in healing acute otitis media.

           Subsiding inflammation                     Meniscus level of thin mucopus.

  with thinner middle ear purulent fluid.

Resolving mucopus with residual tinge of subepithelial haemorrhage along the handle of malleus.

Mild eardrum bulge with minimal residual mucopus along inferior rim of eardrum medially and resolving erythema of vascular strip area.


Resolving mucopus in an otherwise non-inflamed tympanic membrane. 

Viral Bullous Myringitis


Vesicle/bleb arising from the eardrum surface with surrounding inflammations.

 Severely inflamed osseous ear canal and eardrum with glistening bulla seen.


Bulla (+) occuring over cone of light area surrounded by an inflamed eardrum.

      Haemorrhaghic bullous myringitis        Large haemorrhagic bulla (+) which was

                   (bullae - arrows).                          initially thought due to tick by the

                                                                                   referring physician!

 Mixed non-haemorrhagic (1) and haemorrhagic (arrow) bullae of an infected eardrum.  Top left figure is the endoscopic view before treatment and top right 1 week later.  Complete recovery is to be expected.  [1,2,3,4 - bullous lesion]

Another image showing bleb of myringitis (+) affecting right eardrum.

 Multiple blebs of left eardrum.

 Fresh blood from a recently burst haemorrhagic bleb in the left ear canal.  

[TM - tympanic membrane, Star - blood within unruptured blister]

Another example of bullae with recent bleeds.

Bluish blister arising from the osseous meatus skin lining which had caused blocked ear sensation and reduced hearing.

Shrinking haemorrhagic bullous (x).  Arrow - lateral process of mallelus.


Tympanosclerosis is a potential benign complication of acute otitis media, acute myringitis, or post-trauma. Clinically, it appears as a chalky white material within the eardrum substance.  Dense sclerosis, causes eardrum thickening and may involve the ossicles with impairment of hearing (conductive hearing loss). 

[ 1 - retracted pars tensa, 2 - myringosclerosis plaque, 3 - hypotympanic recess]


 Rim of myringosclerosis (white arrows).  [Green arrow - chorda tympani nerve]

Healed eardrum perforation (+) surrounded by global thickening of pars tensa.

Lower quadrant eardrum thickening (rectangle). 

Healed eardrum perforation (+) with tympanosclerosis plaque (x).