Complications of AOM are very rare considering the incidence of the disease Mastoiditis can develop in children with AOM and may include osteitis and subperiosteal abscess formation Patients with mastoiditis present with swelling behind the ear that displaces the auricle outward and downward There is tenderness over the mastoid and the ipsilateral TM is nearly always abnormal in appearance Intravenous antibiotic therapy is generally recommended and surgical drainage may be necessary in more severe cases AOM with mastoiditis that involves the petrous portion of the temporal bone can cause cranial nerve palsies (Gradenigo syndrome) The trigeminal (V) and abducens (VI) nerves are most often affected with facial pain and diplopia as the presenting symptoms The facial (VII) and acoustic (VIII) nerves can also be involved The posterior and middle cranial fossae are adjacent to the middle ear and, on rare occasions, infection can spread to the central nervous system and cause meningitis, extradural abscess, subdural empyema, or brain abscess Any child with AOM and cranial nerve palsy or signs of CNS infection should be evaluated with a CT or MRI to define the extent of the infection TRAUMATIC TM PERFORATION The TM can be perforated by penetrating or blunt trauma to the external ear Insertion of cotton swabs or other instruments to clean cerumen from the ear may lead to TM perforation Blunt trauma from a punch or slap may create a pressure wave in the external canal that causes rupture of the TM Proximity to an explosion, hyperbaric oxygen treatment, deep sea diving, or airplane travel may also rupture the TM Ear pain is often severe but resolves with time On examination, the perforation can usually be visualized, and pneumatic otoscopy will show no movement of the TM with positive or negative pressure Most traumatic perforation will heal spontaneously, but patients with lesions over 20% of the diameter of the TM, acute hearing loss, vertigo, or cranial nerve deficits should be evaluated promptly by otolaryngology for possible surgical intervention Head-injured children with basilar skull fractures may have cerebrospinal fluid otorrhea or hemotympanum on examination With hemotympanum, the TM initially looks red from fresh bleeding with oxygenated blood Over time, the blood deoxygenates and appears dark purple behind the immobile ear drum Basilar skull fractures are associated with many other signs and symptoms including facial nerve palsy, hearing loss, and vertigo In general, the management of the brain injury is the immediate priority REFERRED EAR PAIN