The incidence and implications of positive middle ear pressure shown by tympanometry have been sparsely reported in the literature. A series of 13 patients (16 ears) exhibited middle ear pressures that exceeded +49 mm H2O. Clinical, otoscopic, audiologic, and pathologic findings are reviewed. Otalgia or fullness and pharyngitis were the most commonly reported symptoms. Acute middle ear pathologic conditions were otoscopically confirmed in 13 ears. Effusion was present in five of six ears that were selected for myringotomy. The clinical implications of positive middle ear pressure would be particularly important when screening in a nonmedical setting and in the examination of infants. These findings are also important for considering the role of positive middle ear pressure in the pathogenesis of otitis media.