appearance of white patches) and sometimes tympanosclerosis (white deposits in the middle ear) Spontaneous perforation of the TM usually results in small defects that generally heal rapidly; however, large perforations may persist long after the infection has cleared Ossicular necrosis may also occur in children who have had AOM or OME The incudostapedial joint is most susceptible; erosion can results in disarticulation of the incus from the stapes, resulting in conductive hearing loss As the perforation closes, epithelium from the lateral surface of the TM may become trapped in the middle ear and form a cyst (cholesteatoma) that can expand and erode the structures of the middle ear and surrounding bone AOM may cause inflammation in the inner ear structures (serous labyrinthitis) This causes mild to moderate vertigo with or without a sensorineural hearing loss Any of these findings warrant consultation with an otolaryngologist to determine the need for acute intervention, or if the patient can be safely discharged to specialty follow-up as an outpatient Other complications warrant more acute intervention and urgent otolaryngology consultation: Facial nerve paralysis may occur suddenly during AOM The nerve paralysis may be partial or complete when the child is first examined The facial nerve usually recovers complete function if appropriate systemic (IV followed by oral) antibiotic and corticosteroid therapy is administered and a wide myringotomy with or without tube placement for drainage is carried out as soon as possible Bacterial invasion of the inner ear (suppurative labyrinthitis) causes severe sensorineural hearing loss and severe vertigo that is usually associated with nausea and vomiting Early treatment with IV antibiotics and wide myringotomy with tube placement may prevent permanent inner ear damage Suppurative mastoiditis (acute coalescent mastoid osteomyelitis) may develop, causing destruction of the mastoid air cell system Temporal bone computed tomographic (CT) scans are helpful in differentiating otitis media from mastoiditis Opacified mastoid air cells can be seen in patients with otitis media or mastoiditis, but those with mastoiditis also have radiographic evidence of erosion of the mastoid air cells creating larger opacified spaces As the infection spreads to the postauricular tissues, subperiosteal collection of purulent material displaces the auricle inferolaterally from its normal position The pus may