Ear pus should be distinguished from “oily cerumen”, which is caused by an overproduction of cerumen glands. It is often hereditary. The ear has a persistent pus flow, a peculiar foul odor, and a marginal perforation of the tympanic membrane above the relaxed or tense part of the ear. A grayish white scaly or pea-like substance is visible in the tympanic chamber from the perforation, and it has a strange odor. The deafness is usually mixed if the lesion reaches the cochlea. According to the pathology and clinical manifestations, it is divided into: 1. Simple type: the most common, mostly due to recurrent episodes of upper respiratory tract infection, the pathogenic bacteria invade the tympanic chamber via the eustachian tube. Clinical characteristics are; ear pus, mostly intermittent, mucous or mucopurulent, generally not smelly. The amount of pus varies and increases in the case of upper respiratory tract infections. The tympanic membrane perforation is mostly central in the tension department and varies in size, but there are residual tympanic membranes around the perforation. The tympanic chamber mucosa is pink or pale and may be mildly thickened. The deafness is conductive and generally not heavy. 2. Bone ulcer type: Also known as necrotic or granulomatous type, mostly from acute necrotic otitis media. This type is characterized by persistent pus in the ear, with blood between the pus and often with a foul odor. Large perforations of the tense tympanic membrane may involve the tympanic ring or marginal perforations. There are granulations or polyps within the tympanic chamber and may protrude through the perforation into the external auditory canal. Conduction deafness is more severe. Cholesteatoma: Cholesteatoma is not a true tumor, but a cystic structure located in the middle ear and mastoid cavity. It is called cholesteatoma because it contains cholesterol crystals within the cyst. Differential diagnosis 1. External ear canal swelling: diffuse swelling in the external ear canal opening and ear canal with exuding pulpy secretion, late confined to boils with pus, secretion without mucus, not heavy deafness is its characteristic, pressing on the ear screen is painful, and the lymph nodes behind the ear are often enlarged. 2. Acute tympanitis: often complicated by influenza, the tympanic membrane is congested and forms a large cannon, there is severe ear pain, but there is no perforation or pus flow, the hearing loss is not heavy, and the blood picture is not increased in white blood cells. 3.Secretory otitis media: The most common symptoms of secretory otitis media are stuffy or blocked feeling in the ear, hearing loss and tinnitus, while the systemic symptoms of acute purulent otitis media are heavier, with high fever before tympanic membrane perforation, persistent ear pain, diffuse congestion of the tympanic membrane, and overflow of fluid once perforated.