Severe Acute Otitis Media
||The infection in the middle ear may spread into the fibrous middle layer of the tympanic membrane causing necrosis of a portion of the fibrous middle layer.
The small herniation of the seen in the center of this right tympanic membrane just posterior to the mid portion of the malleus represents such a necrotic area.
The tympanic membrane has lost its strength in the area of necrosis and the pressure of the purulent effusion within the middle ear has caused the epithelium to bulge laterally.
This is the area through which a perforation will shortly develop.