Chronic middle ear infections can be caused by an acute middle ear infection (usually several), blockage of the eustachian tube (the tube that connects the middle ear with the nasal passages), crushing or penetrating injuries to the ear, thermal or chemical burns, or blast injuries. Additionally, children who have head and face abnormalities resulting from chromosomal disorders, such as Down syndrome or cri du chat syndrome, or who have a cleft palate have an increased risk of chronic middle ear infections.

Chronic middle ear infections may flare up after an infection of the nose and throat, such as the common cold, or after water enters the middle ear while bathing or swimming in children who have a perforated eardrum or tubes. Usually, flare-ups result in a painless discharge of pus from the ear (see Ear Discharge). The pus may have a very foul smell.

Children usually have hearing loss and ear discharge. There is usually no pain unless a complication has occurred. Children who have a cholesteatoma may also have white debris in the ear canal.

A doctor diagnoses chronic middle ear infection based on examination findings (for example, when pus drains out of a hole in the eardrum or skinlike material accumulates in the hole or in a pocket in the eardrum). Samples of the pus are sent to a laboratory where bacteria can be grown (cultured).

If a doctor suspects a cholesteatoma or a complication, imaging studies such as computed tomography (CT) or magnetic resonance imaging (MRI) are done.

Doctors may first clean all the debris from the ear. Parents apply ear drops containing an antibiotic and possibly a corticosteroid. Children who have a severe infection are given antibiotics taken by mouth.

If infection lasts or comes back despite the use of antibiotics, doctors may, after a period of time, do a myringotomy with insertion of ventilating (tympanostomy) tubes. If the eardrum is damaged, surgery to repair the eardrum (tympanoplasty) may be done.

A cholesteatoma is removed surgically.