OtoRhinoLaryngology Portal

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Early Stage of Infective Inflammation

Figure shows an increased vascularity and early inflammation of middle ear mucosa in reactivated otitis media (+).  Mucous level is seen anteroinferiorly (arrow). M- malleus handle.  Tympanic membrane still appears normal.

Chronic Suppurative Otitis Media (CSOM): Active Stage

Mucopus discharge in the presence of non-closure eardrum perforation

with intermittently or chronically-diseased middle ear mucosal linings.

Reactivation of otitis media following upper respiratory tract infection.

[(+) - mucopus]

Large central perforation with yellowish discharge.

Bare handle of malleus with active middle ear infection at the background.  


Greenish discharge in Pseudomonas sp. infection.

 Air bubbles within mucopurulent discharge to suggest presence of eardrum perforation. 

 Whitish fibrinous exudates overlying granulation tissue involving the handle

of malleus and corresponding medial wall of the tympanic cavity.


Granulations involving handle of the malleus with unhealthy perforation edges.

Hyperplastic middle ear mucosa with on-going infection.

Large posterior pars tensa perforation with mucopus seen along the external auditory meatus (+).  (A - anterior, P - posterior)

An active infection with double perforation of eardrum seen.



 Large perforation with blood-stained edges in a recently treated chronic otitis media with active infection.

Proper Ear Drop Administration

Healed Infection With Otic Drop Residual In Ear Canal

Small-Size Eardrum Perforation in Chronic Suppurative Otitis Media (CSOM) 

     Small perforation can appear as                With dense myringosclerosis.

a "black dot" on otoscopic examination. 

Small anterior quadrant perforation during inactive stage of CSOM.

Another small anterior quadrant perforation, now involving the right eardrum.


 Small anterosuperior marginal perforation (arrow) with myringosclerotic plaque (+).

Medium-Size Eardrum Perforation in Chronic Suppurative Otitis Media (CSOM)

A medium-sized perforation (estimated 30%) with healthy middle ear mucosa.

A medium-sided perforation (estimated 25%) with thickened edges.  Myringosclerosis plaque seen involving the posterior-inferior quadrant of the TM.



Medium-size posterior pars tensa perforation in inactive stage. 

Large-Size Eardrum Perforation in Chronic Suppurative Otitis Media (CSOM)

 Large central perforation in inactive stage.  The middle ear

mucosa and hypotympanic air cells can be seen clearly.


Large central perforation showing the hypotympanum and Eustachian tube opening anterior-inferiorly.  Posterior pars tensa sclerosis and small fibrous nodule noted at the anterior edge of the perforation.

A very large central perforation with sclerotic plaques seen (+).

A large central perforation of left tympanic membrane.

Large Eardrum Perforation, Myringosclerosis, and Anterior Bony Hump

Large central perforation in inactive stage with plaques of myringosclerosis superiorly in front and behind the handle of malleus.  Anterior bony hump is prominent which limits full view of the eardrum.

Subtotal Eardrum Perforation

Visible promontory and hypotympanic air cells.

Subtotal perforation in quiescent stage with visible ossicles.

 Visible middle ear structures with concurrent osseous canal otomycosis.


The tensor tympani tendon (arrow).


Right subtotal perforation with posterosuperior pocket.

[Credit of this image to Dr Indu Batumalay]

Anatomy of medial wall of the middle ear cavity.  [PR - promontory, M - tip of malleus handle, P - pyramid, (+) - round window niche, yellow dot - oval window with underlying stapes footplate, white arrow - Eustachian tube opening, black arrows - crus of stapes, green arrow - incudostapedial joint, red arrow - stapedius tendon]


NB: In total perforation, the whole tympanic membrane inclusive

of its fibrocartilaginous annular ring is absent.


Hyperplastic middle ear mucosa with polyp formation. 

The eardrum edges became abnormally thickened.  No obvious mucopus seen.

Eardrum Granulations (arrows) Secondary to Recurrent Infection


Granulations (arrows).

Granulations arising from the eardum surface in a poorly-controlled diabetis mellitus and culture positive extended spectrum beta-lactamase resistant Klebsiella pneumonia infection.

Adhesion of Middle Ear Structures

Adhesion band involving head of stapes and mucosa of the upper promontory area (arrow).  (1 - stapedius tendon, 2 - round window niche, 3 - distal end of long process of incus, P - promontory)

CSOM: The Role of Angled Otoendoscopy

 30/45 degree otoendoscopy are useful in the assessment of CSOM.  Its indications include to ascertain ossicular continuity, presence of adhesions, tympanosclerosis, and to look for potential residual focus of infection

prior to myringoplasty.

This image shows the the presence of mucopus from posterosuperior compartment of the middle ear and filling the round window niche.  The discharge is very likely arising from the aditus after it exits mastoid reservoir.


Blob of mucopus occluding eustachan tube opening (circle).

1- handle or malleus tip, 2- round window niche.

30 degree otoendoscopy showing anterior hypotympanum of the right middle

ear cavity focusing at eustachian tube opening (star).  White dots indicates

remnant of tympanic annulus of the eardrum in near-total perforation.

Ear Protection in CSOM

It is important to keep the ear dry to prevent recurring inflammation and subsequent re-infection of the middle ear mucosa in the presence of eardrum perforation.  Water, shampoo, soap, and body bath are amongst the usual agents which need attention.  The methods include wearing shower cap to cover the ear as well, packing the concha with cotton ball smeared with oil-based liquid or cream such as vaseline or olive oil, and using ear plug while taking shower.  Swimming and scuba diving are prohibited, and contact water sports are strongly discouraged until the perforation closed naturally or repaired..

Figure shows packing of the conchal bowl and the introitus of ear canal 

by using  a moldable silicone putty which can be reused after cleaning.

Healed Eardrum Perforation

           Healed eardrum perforation,                      Healed eardrum perforation

    superior quadrant myringosclerosis.             with pars flaccida retained earwax.

Retracted healed eardrum perforation.

Another example of retraction involving healed perforation segment.

Healed large eardrum perforation.

Healed but retracted double eardrum perforations (+) with persistent middle ear effusion.

An apparent eardrum perforation within the healed and atrophic segment surrounded by remaining sclerotic eardrum.

Healed eardrum perforation made 'stand-out' by surrounding myringosclerosis.


Healed eardrum perforation with minimal sclerotic patch (top left) and the outline of the original perforation edges ( top right).