The complications of otitis media are frequently not considered in discussions of the medical or surgical management of this disease. Retrospective review of 135 cases in children treated surgically in an otologic referral practice between 1981 and 1989 revealed that perforation of the eardrum (57 cases) was the most common complication of otitis media, followed by cholesteatoma (54), mastoiditis (16), and atelectasis of the eardrum (eight). Coalescent mastoiditis was most common in children less than 6 years of age, whereas cholesteatoma and ossicular chain destruction occurred more frequently with increasing age. The presenting signs and symptoms of the complications and their management are presented to help alert the practitioner to the potentially severe complications of otitis media.