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A 5-year-old boy presents with ear pain and fever. The left eardrum is inflamed with a small perforation in it and pus is seen in the external canal. A swab of the area grows S. pneumoniae. Which of the following is the most likely mechanism for S. pneumoniae to cause otitis media?
hematogenous spread
direct extension from the nasopharynx
direct inoculation on the ear
spread through lymphatic tissue
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