Chronic Otitis Media, Cholesteatoma And Mastoiditis


What Is It?

Chronic otitis media describes some long-term problems with the middle ear, such as a middle-ear infection (otitis media) that doesn’t improve or keeps returning and a hole (perforation) in the eardrum that does not heal.

The middle ear is a small bony chamber with three small bones — the malleus, incus and stapes — covered by the eardrum (tympanic membrane). Sound is passed from the eardrum through the middle-ear bones to the inner ear, where the nerve impulses for hearing are created. The middle ear is connected to the back of the nose and throat by the eustachian tube, a narrow passage that helps to control the air flow and pressure inside the middle ear. Inflammation or infection of the middle ear can occur when the eustachian tube becomes blocked, for example, when someone has a cold or allergies. When fluid remains in the middle ear, the condition is called chronic serous otitis media.

Sometimes a middle-ear infection causes a hole (perforation) in the eardrum. A hole that does not heal within six weeks is called chronic otitis media. Chronic otitis media caused by a persistent hole in the eardrum can take one of three forms:

  • Non-infected chronic otitis media — There is a hole in the eardrum but no infection or fluid in the middle ear. This condition can exist indefinitely. As long as the ear remains dry, the middle and inner ears can remain stable for years. Repairing the hole is only necessary to improve hearing or to prevent infection.

  • Suppurative (filled with pus) chronic otitis media — This happens when there is a hole in the eardrum and an infection in the middle ear. Cloudy and sometimes foul-smelling fluid drains out through the opening. Treatment with antibiotics usually helps to clear the active infection.

  • Chronic otitis media with cholesteatoma — A persistent hole in the eardrum sometimes can lead to a cholesteatoma, a growth (tumor) in the middle ear made of skin cells and debris. A cholesteatoma also can form when there is no perforation. In this case, it is caused by blockage of the eustachian tube. (Congenital cholesteatomas are present at birth and are not caused by a persistent perforation. The exact cause is not known but they occur behind an intact eardrum.) Cholesteatomas can cause hearing loss and are prone to get infected, which can cause ear drainage. Cholesteatomas will grow large enough to erode the middle-ear structures and the mastoid bone behind the middle ear.

Problems with the middle ear, such as fluid in the middle ear, a hole in the eardrum or injury to the small, middle-ear bones can cause hearing loss. In rare situations, infections in the middle ear can spread deeper inside the inner ear, causing hearing loss and dizziness. Rare, but serious, complications include brain infections, such as an abscess or meningitis. Facial-nerve injury and facial paralysis also can occur when there is chronic infection and a cholesteatoma.

Children have an increased risk of having acute otitis media. Because of this, they have an increased risk of developing chronic otitis media as well. In general, doctors believe that children have an especially high risk of all types of ear infections because of several factors, including:

  • Immature immune (infection-fighting) system
  • Undiagnosed allergies
  • Differences involving the size and shape of the eustachian tube (smaller and less angled compared to an adult)
  • Unusually large or infected adenoids (masses of infection-fighting tissue in the throat, near the opening of the eustachian tubes)
  • Exposure to cigarette smoke
  • Attendance at day care


Chronic otitis media caused by a persistent hole in the eardrum can be present for years with no symptoms or only mild hearing loss. There may be mild ear pain or discomfort. When infection occurs, drainage starts from the ear and hearing loss can worsen.

Symptoms that can indicate a more serious condition, and that require immediate attention, include:

  • Severe pain, dizziness and facial-nerve injury (facial weakness)
  • Swelling, tenderness and redness behind the ear, which may indicate spread of infection to the mastoid bone (mastoiditis)
  • Fever, headache and confusion


The doctor will ask about a history of ear infections, treatments used and any previous ear surgery. The doctor also will want to know about any medications being taken to treat an ear problem, including the type, dose, and length of treatment.

The doctor may suspect chronic otitis media based on a history of prior ear infections and/or persistent ear drainage. To confirm the diagnosis, he or she will look inside the ear with a special light called an otoscope and may take a sample of drainage fluid to be examined in a laboratory.

When further evaluation and treatment is needed, a referral may be made to an otolaryngologist, a doctor who specializes in treating disorders of the ears, nose and throat. If the otolaryngologist suspects mastoiditis or a cholesteatoma, additional tests may be needed. These could include X-rays, a computed tomography (CT) scan or a magnetic resonance imaging (MRI) scan. If there is any concern that hearing may have been affected, it can be evaluated by a test called an audiogram.

Expected Duration

The duration of symptoms is variable. Antibiotic treatment of the infection causing the chronic otitis media may be enough to stop the ear from draining. Sometimes, despite appropriate antibiotics, the infection persists and surgery may be necessary to remove the infected tissue and repair the eardrum perforation and any injury to the ossicles. A cholesteatoma usually requires surgical removal.


Since chronic otitis media typically is a complication of acute otitis media, getting prompt and thorough treatment and follow-up of acute ear infections may help to prevent this chronic infection. A child with chronic eustachian tube problems may need special tubes (tympanostomy tubes) inserted into his or her eardrums to prevent repeated ear infections by allowing air to flow normally in the middle ear.

After recovering from an infection, a perforated eardrum may need to be repaired to prevent another infection.


Treatment of suppurative chronic otitis media typically first involves a course of antibiotics taken by mouth and antibiotic eardrops together with aspiration (suctioning) of the draining middle ear fluid. Most infections will clear up with this treatment unless a cholesteatoma is present. A cholesteatoma can be the source of repeated infections, and often must be removed with surgery.

Surgery to repair a persistent hole in the eardrum may be recommended. However, in some cases, the hole is left open because it can act like a tympanostomy tube to allow air to flow through the middle ear and possibly prevent more infections.

When a chronic ear infection spreads beyond the middle ear to the mastoid bone (the portion of bone behind the middle ear), a serious infection called mastoiditis can occur. Intravenous (IV) antibiotics often can clear up this infection, but surgery may be necessary.

When To Call A Professional

Call your doctor immediately if you or your child develop a cloudy or foul-smelling discharge from one or both ears, or have difficulty hearing. Also, seek emergency care for fever, swelling, tenderness or redness behind the ear, persistent or severe ear pain, dizziness, headache, confusion or facial weakness.


With prompt antibiotic treatment and ear aspiration, the prognosis is excellent. About nine out of 10 patients are free of infection after this therapy. Surgery usually is necessary to correct a persistent eardrum perforation or to remove a cholesteatoma. The timing of the surgery depends upon the response to antibiotics as well as the presence of complications of the infection. Resolution of the infection is almost always possible. Restoration of hearing depends upon the extent of damage and healing after surgery.

Johns Hopkins patient information

Last revised:

Diseases and Conditions Center

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All ArmMed Media material is provided for information only and is neither advice nor a substitute for proper medical care. Consult a qualified healthcare professional who understands your particular history for individual concerns.