A 5-year-old boy presents to the clinic for evaluation of symptoms of left ear pain and associated fever. On physical examination, the left eardrum is inflamed with a small perforation in it and pus is seen in the external canal. A swab of the fluid 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