Bacteriology of Pharyngitis in Suppurative Otitis Media Cases

Egyptian Journal of Medical Microbiology, July 2009 Vol. 18, No. 3 

Bacteriology of Pharyngitis in Suppurative Otitis Media Cases 

Mona F. Salama*, Alaa Ali Abou-Bieh 

Departments of Medical Microbiology and Immunology* and Otolaryngology, 

Faculty of Medicine, Mansoura University 

ABSTRACT 

Problem Addressed: Unexplained persistent or recurrent bacterial pharyngitis in some patients who are 

suffering from infected middle ear cleft. Patients and Methods: Bacteriological swabs were obtained 

from both ears and pharynx of thirty-seven cases with chronic otorrhea and perforation, who are 

complaining of recurrent or persistent sore throat. Isolation and identification of the micro-organisms 

were done. Isolated Gram-negative bacilli were subjected to further identification by biochemical 

reactions and antimicrobial susceptibility testing using modified Kirby Bauer disk diffusion method. 

Identical isolates from the same patient (ear and pharyngeal swabs) were subjected to further 

identification by genotyping using the pulsed field gel electrophoresis technique (PFGE). Results: Six 

cases (16%) showed identity in both phenotypes and genotypes for ear and pharyngeal samples from the 

same patient. Four of the isolates were Pseudomonas aeruginosa, one was Proteus mirabilis, and one 

was Escherichia coli. None of these three species is known to be among the primary organisms that may 

cause pharyngitis. Conclusion: Bacterial pharyngitis in patients with chronically infected middle ear 

cleft may be attributed to the same organism invading the middle ear mucosa. In addition, this study 

highlights some organisms as pharyngeal invaders although they are not among the previously 

documented causes of bacterial pharyngitis. However, the study does not confirm the method of spread of 

these organisms between the middle ear cleft and the pharynx and does not prove whether the spread was 

directly via the eustachian tube, or not. The study correlates the causative organism of the middle ear 

infection and that infected the pharyngeal mucosa by using phenotypic and genotypic bacteriological 

identification and typing methods. 

Key Words: Chronic suppurative otitis media, Pharyngitis, Pulsed field gel electrophoresis. 

INTRODUCTION 

Chronic throat soreness is a common 

complaint. Nowadays it is attributed to a wide 

range of etiologies. It was noteworthy that the 

chronic throat soreness complaint of some 

patients, whom are at the same time suffering 

from chronically infected middle ear cleft, could 

not be attributed to any of the known 

etiologies (1) . 

The aim of the present study is to investigate 

whether the reason of this complaint is related 

to a bacteriological causative agent or not. In 

addition, if the cause would be bacteriological, 

we aim to find if there is any correlation 

between the causative organism of the middle 

ear infection and that infected the pharyngeal 

mucosa using phenotypic and genotypic 

bacteriological identification and typing 

methods. 

PATIENTS 

This is a prospective study. The inclusion 

criteria for cases were being a known case of 

chronic suppurative otitis media and presented 

with chronic sore throat as the principal 

complaint. Thirty-seven cases met these criteria 

over the eight months study period and were 

included in the study population. 

All cases were adults as pediatric patients 

were excluded due to the high incidence of 

recurrent attacks of acute tonsillitis and acute 

pharyngitis. The age ranged between seventeen 

and seventy-two with mean fifty-four. There 

were twenty-two males and fifteen females. 

Eight of the males were smokers. 

All cases were suffering from persistent or 

recurrent otorrhoea together with tympanic 

membrane perforation. Nineteen patients had 

the disease in both ears, ten in the right ear and 

eight in the left ear. Six ears have been 

previously operated upon with persistent 

mastoid and / or tympanic cavity infection. Two 

cases had cholesteatoma but patients were 

reluctant to undergo surgery. All ears with 

mixed infection or superadded fungal infection 

were excluded from the study. In most of cases, 

the sore throat complaint was in the form of 

recurrent attacks. Some patients noticed or 

could remember an on / off relation between 

1


some soreness attacks and otorrhea bouts. Other 

patients complained of persistent chronic 

soreness. 

Other etiologies for chronic throat soreness 

in adults were assessed in these patients. Any 

form of upper aero-digestive tract neoplasia was 

excluded. Although this would not exclude 

gastroesophageal reflux disease (GERD) or 

laryngopharyngeal reflux (LPR), but none of the 

patients showed any hiatal hernia, reflux, or 

delayed gastric emptying in the barium swallow 

/ upper GI series. Two patients also were 

subjected to upper gastrointestinal endoscopy 

(one was prior to his inclusion in the study). 

During the time of study five patients were on 

antireflux treatment included even proton pump 

inhibitors with minimal or no pharyngeal 

symptoms relieve. None of the patients had 

history of previous deep neck spaces 

suppuration, any foreign body ingestion or 

recent neck trauma. In addition, autoimmune 

and hematological conditions were excluded. 

Blood iron was assessed in all females. Two 

patients had frequent cement exposure and one 

patient with smoke exposure due to their 

occupation. Nine patients had their tonsils 

removed (all more than ten years before the 

study time). Eleven patients had postnasal drip 

on examination, four of them showed chronic 

sinusitis on radiological evaluation (all patients 

had bacteriological swabs from their nasal 

cavities on further step during the study). Five 

of the eleven patients had used local nasal 

steroids before. One patient with cleft palates 

and lip had them surgically repaired eighteen 

years ago. Two were diabetic patients and four 

were hypertensive, two of them were on ACE 

inhibitors and another one was on B blocker. 

One patient was asthmatic and on Fluticasone 

propionate inhaler. 

All patients were asked to stop topical and 

systemic antibiotics ten days at least prior to 

samples collection. All patients were informed 

about their inclusion in the study. A written 

consent was obtained from all of them. 

METHODS 

Specimens: 

Simultaneous swabs from the ear discharge, 

the posterior pharyngeal wall and bilaterally 

from the nasal cavities from each patient were 

obtained. This was done at three different 

successive settings. MDIC ® sterile swabs (Ajax, 

Ontario, Canada) were used. Swabs were taken 

under proper precautions. They were taken 

under direct visualization or endoscopically 

guided, after proper external ear canal suction 

and were collected as deep as possible, using 

sterile instruments. 

Isolation and identification of microbial 

isolates: 

Direct Gram stained films for all specimens 

were prepared and studied first. Then all 

specimens were inoculated on proper culture 

media with incubation at 37 o C for 24 - 48 hours 

aerobically. These media were blood agar and 

MacConkey’s agar. Then all the isolated 

organisms were identified according to standard 

microbiological methods and, where necessary, 

the API (Analytical Profile Index) system 

(bioMerieux, France) was used. Antimicrobial 

susceptibility test (Antibiotyping) for aerobic 

bacteria was performed. This was done by using 

modified Kirby - Bauer disk diffusion method (2) , 

and according to the Clinical and Laboratory 

Standards Institute/NCCLS breakpoints for 

interpretation of results (3) , using the following 

antimicrobial discs and concentrations: 

Amikacin ® (AK), 30 mg, 

Amoxacillin/Clavulanic ® acid (AMC), 30 mg, 

Aztereonam ® (ATM), 30 mg, Cefotaxime ® 

(CTX), 30 mg, Cephradine ® (CE), 30 mg, 

Ciprofloxacin ® (CIP) 5 mg, Clindamycin ® 

(DA), 2 mg, Erythromycin ® (E), 15 mg, 

Imipenum ® (IPM), 10 mg, Trimethoprim - 

Sulphamethoxazole ® (SXT), 25 mg, 

Tetracyclin ® (TE), 30 mg and Ceftazidime ® 

(CAZ), 30 mg. Apart from the standard 

antibiotics, testing was also done specifically for 

Gentamicin ® (CN), 10 mg and 

Chloramphenicol ® (C), 30 mg which are 

available locally as topical antibiotic eardrops. 

Isolates were considered to belong to different 

antibiotypes if at least one difference in 

antibiotic susceptibility was observed (4) . Isolates 

from the same patient (ear and pharyngeal 

swabs) which showed the same antibiotype 

were suspected to be related to the same strain, 

and were subjected to further identification for 

confirmation by genotyping using pulsed field 

gel electrophoresis (PFGE). 

The genotyping by pulsed field gel 

electrophoresis was done using the technique 

described by Tenover et al. (5) to evaluate the 

relatedness of the isolates. First, organisms were 

grown overnight to plateau phase were 

embedded in low-melt agarose and digested for 

24 hours each, first with lysozyme and then with 

proteinase K, both adjusted to 1 mg/mL. The 

resultant, which was exposed bacterial DNA, 

was then digested with selected endonuclease 

2


restriction enzymes designed to yield ten to 

twenty-five large fragments. These 

endonuclease restriction enzymes were: XbaI 

for Enterobacter, Klebsiella, Citrobacter, and 

Stenotrophomonas; NotI for Escherichia coli; 

SpeI for Pseudomonas and Serratia; and SmaI 

for Acinetobacter. DNA fragments then were 

separated on 1% agarose gels using 

preprogrammed protocols as recommended by 

the manufacturer of the apparatus (Biorad 

CHEF GenePath System, Hercules, CA). 

According to the number of band differences 

isolates were divided into: 1) indistinguishable, 

if their restriction patterns have the same 

numbers of bands, 2) closely related, if their 

restriction patterns result in two to three bands 

difference, 3) possibly related, if their restriction 

patterns result in four to six bands difference 

and 4) unrelated, if their restriction patterns 

result in seven or more bands difference. 

Organisms were defined as concordant when 

they differed by three or fewer bands after 

visual inspection of the restriction endonuclease 

pattern. Isolates that were proven to have the 

same antibiotype, and were closely related by 

PFGE were considered to belong to same 

strains (6) . 

RESULTS 

Table (1) shows the bacteriology of the 

eighteen cases with unilaterally infected middle 

ear cleft. Pseudomonas aeruginosa was the 

most commonly detected organism (nine cases), 

while Proteus mirabilis was the next 

encountered organism (five cases). The situation 

was nearly close in the nineteen cases with 

bilaterally infected middle ear clefts (table 2). 

Proteus mirabilis was detected in seven cases in 

both ears and in one ear only in two cases. 

Pseudomonas aeruginosa was detected in both 

ears in six cases and in one ear in the two cases 

with Proteus in the opposite side. Gram-positive 

organisms were only detected in two cases 

where middle ear was unilaterally involved. 

Bacteriological pharyngeal swabs findings were 

significant in nineteen cases (table 3). Group A- 

β hemolytic Streptococcus pyogenes was the 

most commonly encountered species (nine 

cases), while four other cases showed α - 

hemolytic Streptococci and Staphylococci. 

Gram-negative species could be detected in six 

cases, four of them were Pseudomonas 

aeruginosa, one was Proteus mirabilis and the 

last was Escherichia coli. Nasal cavities isolates 

were nine cases with Streptococcal pneumoniae 

and one case with Klebsiella isolate. 

Into a further step of organisms 

identification, and as mentioned above, isolates 

from the same patient (ear and pharyngeal 

swabs) which showed the same phenotyping 

and were identical in antibiotyping (Fig 1) were 

suspected to be related to the same strain, and 

were subjected to further identification for 

confirmation by genotyping using pulsed field 

gel electrophoresis (PFGE). Then after the 

results of PFGE (Fig 2), isolates that were 

proven to have the same antibiotype, and were 

closely related by PFGE were considered to 

belong to same strains. By following this 

stepwise technique, the study could recognize 

identity in both phenotypes and genotypes for 

different samples from the same patient (ear and 

pharynx) in all the six cases with Gram-negative 

isolates from pharyngeal swabs (Tables 4 & 5). 

These cases were representing sixteen percent 

of the study cases. 

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Table (1): Bacteriology of infected middle ear cleft in unilaterally involved cases 

Bacteria 

No. of Cases 

Pseudomonas aeruginosa 9 

Proteus mirabilis 5 

Escherichia coli 1 

Klebsiella sp. 1 

Streptococcus sp. 1 

Staphylococcus epidermidis 1 

- Total number of cases 18 - sp. = species 

Table (2): Bacteriology of infected middle ear cleft in bilaterally involved cases 

Bacteria 


Proteus mirabilis (in both ears) 7 

Pseudomonas aeruginosa (in both ears) 6 

Proteus mirabilis (in one ear) & Pseudomonas aeruginosa (in other ear) 2 

Escherichia coli (in both ears) 2 

Klebsiella sp. (in both ears) 1 

Enterobacter sp. (in both ears) 1 


Table (3): Bacteriology of pharyngeal swabs in all study cases 

Bacteria 





Group A-β hemolytic Streptococcus pyogenes 9 

α - hemolytic Streptococci 2 

Staphylococcus sp. 2 

No significant growth in 3 swabs 18 


Table (4): Detected identity in both phenotypes and genotypes for different samples from the same 

patient 

Bacteria 





- Total number of cases 6 

Table (5): Detected identity in both phenotypes and genotypes for different samples from the same 

patient 

Bacteria 


Pseudomonas aeruginosa (in one ear) 3 

Pseudomonas aeruginosa (in both ears) 1 

Proteus mirabilis (in both ears) 1 

Escherichia coli (in both ears) 1 

- Total number of cases 6 

4


Right Ear 

Left ear 

Pharynx 

Fig 1: Isolates from the same patient (both ears and pharyngeal swabs) showing the same antibiotype 

5


Fig 2: Detected identity in genotypes for different samples from the same patient (Arrow 1: Right Ear, 

Arrow 2: Left Ear, Arrow 3: Pharynx, Black Arrow: Marker) 

DISCUSSION 

The study idea came from an observation for 

some cases of chronic suppurative otitis media 

in the outpatient department. Those cases, 

although very few, drew the attention to some 

serious results. Chronic suppurative otitis media 

is a condition which necessitates patient to 

follow up for a long period either pre or 

postoperatively. Usually the symptoms and 

reasons that oblige the patient to seek medical 

advice are related to the otorrhea, hearing loss 

or that related to sequelae or complications of 

the disease. For those cases who triggered this 

study, the main reason for seeking medical 

advice was a long history of throat soreness. In 

some of them, it was so annoying and 

incapacitating for a normal daily life. Even one 

of the patients was already getting a psychiatric 

counseling when he joined the study. Also, most 

of the cases when joined were already 

investigated for the throat complaint either in 

our hospital or in other places. These 

investigations revealed either no clear reason for 

the throat complaint or when the reason they 

revealed were treated, very limited 

improvement could be achieved. Some special 

data highlighted a questionable relation between 

the otologic problem and the pharyngeal 

problem. An on / off relation between the sore 

throat and the otorrhea was the first special 

symptom demonstrated from the first patient 

trigged the study. After several years of 

recurrent attacks of otorrhea, the patient could 

realize that shortly after the start of the otorrhea 

attack he usually develop a period of severe 

soreness in his throat. This is usually without 

any other systematic manifestation apart from 

marked malaise and halitosis locally. This 

on/off relation could be demonstrated in other 

cases joined the study later, although some 

others noticed that this soreness is persistent in 

its nature. Another remark by some patients was 

that only certain antibiotics would be effective 

with the pharyngeal problem. As mostly the 

otorrhea was treated by local treatment, patients 

noticed that their throat soreness usually not 

improve by usual antibiotics and most of them 

6


knew that they need some different antibiotic to 

improve (mostly was from the Quinolones 

group). In addition, in one of the early study 

cases and during an attack of otorrhea, a swab 

was taken from his pharynx, then we got an 

early note from the microbiology laboratory 

about a Gram-negative very similar to that 

caused the patient’s otorrhea could be 

demonstrated in the pharyngeal swab. 

According to this, we proceeded to investigate 

the case and a phenotype identity could be 

assured between ear and pharynx samples in this 

patient. So this study was designed to 

understand this findings and try to find if this 

was an isolated situation or it can be 

demonstrated in other cases (repeatable and 

demonstrable). 

The protocol for the study was to investigate 

any case met the case selection criteria 

(mentioned above in the patients section) and 

try to find if its throat complaint is due to a 

bacteriological causative agent or not and 

whether this agent is related to the same one 

involved in the ear problem. To ensure 

achieving this, we tried to demonstrate this both 

phenotypically by the regular microbiological 

methods and genotypically by a more accurate 

method. This is because it is known that the 

goal of strain typing studies is to provide 

laboratory evidence that phenotypically related 

isolates are also genetically related and thus 

represent the same strain (Tenover et al. 1995) 

and subtyping of isolates to the strain level has 

been increasingly important in order to verify if 

organisms are clonally related, i.e. have a 

common origin (7) . Several approaches have been 

used for subtyping of bacterial isolates, 

including both phenotyping and genotyping so 

called fingerprinting methods; flagellin typing 

(Fla), random amplified polymorphic DNA 

(RAPD), amplified fragment length 

polymorphism (AFLP), multilocus enzyme 

electrophoresis (MEE), nucleotide sequencing 

(NS), polymerase chain reaction (PCR) and 

pulse field gel electrophoresis (PFGE) (8) . 

Genotyping methods may be compared based 

on a range of criteria, including sensitivity, 

availability, reproducibility, rapidity, ease of 

use, and cost. One of the most important 

characteristic is discriminatory power of the 

technique (8) . The genotyping by the pulsed field 

gel electrophoresis technique was chosen 

because it is a genomic-based method that has 

been successfully used for the subtyping of 

several bacterial species (9,10) . Except for the long 

time need (the whole procedure can take as long 

as four days) and being an expensive method 

that requires sophisticated equipment, pulsed 

field gel electrophoresis is the genotyping 

method that proven to be superior to most other 

biochemical and molecular typing methods with 

its high discriminatory powers regarding 

different bacterial strains (11) . 

Besides detecting of a bacteriological 

causative agent for pharyngitis in sixteen 

percent of the study population whom were 

suffering for years without known etiology, the 

results in general presented another two main 

end-points. First, is recognizing identity in both 

phenotypes and genotypes for ear and pharynx 

samples of the same patient. Second, is 

demonstrating Gram-negative isolates from 

pharyngeal swabs that are not known to be 

among the primary organisms which may cause 

pharyngitis. 

On reviewing the previously published 

studies, the primary causative bacterial 

organisms of chronic suppurative otitis media 

may be aerobic including Pseudomonas 

aeruginosa, Escherichia coli, Staphylococcus 

aureus, Streptococcus pyogenes, Proteus 

mirabilis and Klebsiella species or anaerobic 

including Bacteroides, Peptostreptococcus and 

Proprionibacterium. Bacteria that may lead to 

acute suppurative otitis media on top of chronic 

suppurative otitis media include Streptococcus 

pneumoniae, Staphylococcus aureus, 

Haemophilus influenzae and Micrococcus 

catarrhalis. These are respiratory pathogens that 

may have been insufflated from the 

nasopharynx into the middle ear through the 

Eustachian tube during bouts of upper 

respiratory infections (12) . Pseudomonas 

aeruginosa has been particularly blamed for the 

deep-seated and progressive destruction of 

middle ear and mastoid structures through its 

toxins and enzymes (13) . Our present study 

findings regard the bacterial causatives of 

chronic ear active infection (or even if it was 

acute on top of chronic infection) are almost the 

same as these published literatures (Tables 1 & 

2). 

Meanwhile the published studies about 

primary causative organisms of bacterial 

pharyngitis showed that bacterial pharyngitis is 

less common than viral and its single most 

frequent cause is Group A-β hemolytic 

Streptococcus pyogenes. They found other 

bacterial causes include Group C, G, F 

streptococci, Arcanobacterium haemolyticum, 

Neisseria gonorrhoeae, Treponema pallidum, 

Chlamydia pneumoniae, Mycoplasma 

7


pneumoniae, Mycobacterium tuberculosis 

Francisella tularensis, Corynebacterium 

diphtheriae, Yersinia enterocolitica and 

Yersinia pestis (14,15,16) . In addition, the normal 

throat inhabitants are Staphylococcus aureus, 

Streptococcus viridans, Bacteroids, 

Haemophilus influenzae, Haemophilus 

parainfluenzae, Escherichia coli and 

Enterobacteriaceae (17) . In our present work also, 

the main organism detected was the Group A-β 

hemolytic Streptococcus pyogenes (Table 3). 

The difference between our results and the other 

published studies is the detection of three types 

of organisms in sixteen percent of cases that are 

not mentioned in the literature as primary 

causative of bacterial pharyngitis. These are 

four Pseudomonas aeruginosa cases, one 

Proteus mirabilis case and one Escherichia coli 

case (Tables 4 & 5). This finding together with 

having the study could recognize identity in 

both phenotypes and genotypes for different 

samples from the same patient (ear and 

pharynx) in all of these six cases, would prove 

that bacterial pharyngitis in patients with 

chronically infected middle ear cleft may be 

attributed to the same organism invaded the 

middle ear mucosa. This also would explain the 

chronological relation between the patients’ 

otorrhea and throat symptoms and these 

symptoms improvement with antibiotics that 

affects Gram-negative organisms either before 

or during the study. Moreover, this would 

explain the severity of symptoms in some cases 

as these organisms are known by producing 

destructive toxins and enzymes and may lead to 

pharyngeal muscles and structures inflammation 

rather than the simple mucosal inflammation 

caused by the usual pathogens (18) . 

The study could not confirm the method and 

the route of spread of these organisms between 

the middle ear cleft and the pharyngeal area and 

if this might be through the eustachian tube. In 

addition, it could not explain why these 

organisms were not detected in the results of the 

nasal swabs, which were taken simultaneously 

with the pharyngeal swabs. Although we 

suggest that, this may be due to the action of the 

nasal mucociliary transporting function and its 

direction toward the pharynx and away from the 

nasal cavities (19) . Another item worth enough to 

be noticed, negative pharyngeal swabs in 

suspected cases like those included in this study, 

should not be consider conclusive. As we 

noticed during our work, the timing of 

pharyngeal swab in relation to the onset of 

otorrhea is very important. 

CONCLUSION 

Bacterial pharyngitis in patients with 

chronically infected middle ear cleft may be 

attributed to the same organism invaded the 

middle ear mucosa. In addition, this study 

highlights some organisms as pharyngeal 

invaders (under special circumstances) although 

they are not among the previously documented 

causatives of bacterial pharyngitis. 

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البكتريا المسببة لإلتهاب الحل ق في حالات التهاب الأذن الوسطى التقيحي 

* 

- 

د.‏ منى فودة سلامة د.‏ علاء علي أبو بيه 

من قسمي الميكروبيولوجيا والمناعة الطبية و الأذن والانف والحنجرة*‏ 

– آلية طب المنصورة 

، 

يعاني بعض مرضى التهابات الأذن الوسطى من التهاب دائم او مرتجع بالحلق ، وتهدف هذه الدراسة إلى معرفة ما إذا آان 

مسبب هذا الإلتهاب بكتيري أم لا آما تهدف لمعرفة وجود أي ارتباط بين البكتيريا المسببة لالتهاب الاذن الوسطى وتلك 

الموجودة بالحلق وذلك عن طريق طرق التصنيف الميكروبي الظاهري والجيني.‏ 

وقد اشتملت هذه الدراسة على سبع وثلاثين حالة تعاني من الإصابة بالتهاب صديدي مزمن بالأذن الوسطى وتعاني في الوقت 

نفسه من التهاب مزمن بالحلق.‏ وقد تم أخذ مسحات بكتيرية متزامنة ومتعددة من الاذنين و الحلق والبلعوم وتم عزل 

الميكروبات الموجودة بالاذن والحلق وتم فحصها عن طريق أفلام مصبوغة بالجرام من المسحات مباشرة قبل وبعد زراعتها 

على الأوساط البكتيرية.‏ ثم خضعت الميكروبات سالبة الجرام المسببة للإلتهاب للتصنيف الظاهري عن طريق اختبار 

الحساسية للمضادات الحيوية والإختبارات الكيميائية ثم التصنيف الجيني باستخدام الفصل الكهربائي متعدد المجال.‏ 

وقد أثبتت الدراسة وجود تطابق ظاهري وجيني للسلالات الميكروبية المسببة لالتهاب الأذن الوسطى والبلعوم في ١٦% من 

الحالات ، وقد عزل ميكروب الزائفة الزنجارية aeruginosa) (Pseudomonas من حلق أربع حالات وميكروب 

الإشريكية القولونية من حالة وميكروب المتقلبة الرائعة mirabilis) (Proteus من حالة أخرى.‏ و المعروف ان 

أي من هذه الميكروبات الثلاث غير مصنف من الميكروبات الأولية المسببة لالتهاب الحلق.‏ 

وقد خلصت هذه الدراسة إلى ان التهاب الحلق والبلعوم في بعض المرضى المصابين بالتهاب الأذن الوسطى التقيحي يمكن أن 

يعزى لنفس الميكروب الموجود بالأذن الوسطى آما اثبتت ان بعض الميكروبات التي لم تكن مصنفة من قبل آمسببات اولية 

لالتهاب البلعوم يمكن ان تتسبب في التهاب الحلق والبلعوم تحت شروط خاصة.‏ 

(E.coli) 

10

Bacteriology of Pharyngitis in Suppurative Otitis Media Cases

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