Ear discharge (otorrhea) is drainage exiting the ear. It may be serous, serosanguineous, or purulent. Associated symptoms may include ear pain, fever, pruritus, vertigo, tinnitus, and hearing loss.
Etiology of Otorrhea
Causes of ear discharge may originate from the ear canal, the tympanic membrane, the middle ear, or the cranial vault. Certain causes tend to manifest acutely because of the severity of their symptoms or associated conditions. Others usually have a more indolent, chronic course but sometimes manifest acutely (see table Some Causes of Ear Discharge).
Overall, the most common causes are
Acute otitis media with perforation
Chronic otitis media (with a perforation of the tympanic membrane, cholesteatoma, or both)
The most serious causes are necrotizing otitis externa (previously called malignant otitis externa), basilar skull fracture, and cancer of the ear.
Some Causes of Otorrhea
Cause | Suggestive Findings | Diagnostic Approach |
|---|---|---|
Acute discharge* | ||
Acute otitis media with perforated TM | Severe pain, with relief on appearance of purulent discharge | History and physical examination Sometimes audiogram Sometimes high-resolution temporal bone CT if a complication of acute otitis media (eg, subperiosteal abscess, new onset vertigo or dizziness, facial nerve weakness/paralysis) is suspected |
Otorrhea in patients with chronic perforation, sometimes with cholesteatoma Can also manifest as chronic discharge | Sometimes history and physical examination alone Sometimes high-resolution temporal bone CT Sometimes audiogram | |
Significant, clinically obvious head injury or recent surgery Fluid ranges from crystal clear to pure blood | High-resolution CT of the brain and skull base MRI | |
Otitis externa (infectious or allergic) | Infectious: Often after swimming, local trauma; marked pain, worse with ear traction Often a history of chronic ear dermatitis with itching and skin changes Allergic (contact dermatitis): Often after use of ear drops; more itching, erythema, less pain than with infectious Typically involvement of earlobe, where drops trickled out of ear canal Both: Canal very edematous, inflamed, with debris; normal TM | History and physical examination alone |
Post-tympanostomy tube | After tympanostomy tube placement May occur with water exposure | History and physical examination alone |
Chronic discharge | ||
Discharge often bloody, mild pain Sometimes visible lesion in canal Easy to confuse with otitis externa early on | Biopsy CT MRI in some cases | |
History of TM perforation Flaky squamous debris in ear canal (dead skin), retraction pocket in TM filled with keratin debris or dead skin Sometimes polypoid mass or granulation tissue over the cholesteatoma | CT Culture Sometimes diffusion weighted MRI to assess extension into the mastoid or intracranial extension | |
Long history of ear infections or other ear disorders Less pain than with external otitis Canal macerated, granulation tissue TM immobile, distorted, usually visible perforation | Sometimes history and physical examination alone Usually culture | |
Usually in children Drainage foul-smelling, purulent Foreign body often visible on examination unless marked edema or drainage | History and physical examination alone | |
Often fever, history of untreated or unresolved otitis media Redness, tenderness over mastoid | CT with contrast | |
Usually history of immune deficiency or diabetes Chronic severe pain Periauricular swelling and tenderness, granulation tissue in ear canal Sometimes facial nerve paralysis or dysfunction of other cranial nerves (9, 10, 11, 12) | CT and MRI are complementary and are recommended Sometimes radionuclide studies (eg,technetium-99 and gallium scans) Culture | |
Often with respiratory tract symptoms, chronic rhinorrhea, arthralgias, and oral ulcers | Urinalysis Chest radiograph Antineutrophilic cytoplasmic antibody testing Biopsy Nasolaryngoscopy to assess for other commonly affected sites (eg, septum, subglottis) | |
* < 6 weeks | ||
CSF=cerebrospinal fluid; CT = computed tomography; MRI = magnetic resonance imaging; TM = tympanic membrane. | ||
Evaluation of Otorrhea
History
History of present illness in patients with ear discharge should cover duration of symptoms and whether symptoms have been recurrent. Important associated symptoms include pain, itching, decreased hearing, vertigo, and tinnitus. Patients are questioned about activities that can affect the canal or tympanic membrane (eg, swimming; insertion of objects, including cotton swabs; use of ear drops). Head trauma sufficient to cause a cerebrospinal fluid (CSF) leak is readily apparent. If a patient with obesity, sleep apnea, positional headaches, or blurry vision has spontaneous CSF otorrhea, idiopathic intracranial hypertension must be suspected.
Review of systems should seek symptoms of cranial nerve deficit and systemic symptoms suggesting granulomatosis with polyangiitis (eg, nasal discharge, cough, joint pains).
Past medical history should note any previous known ear disorders, ear surgery (particularly tympanostomy tube placement), and diabetes or immunodeficiency.
Physical examination
Examination begins with a review of vital signs for fever.
Ear and surrounding tissues (particularly the area over the mastoid) are inspected for erythema and edema. The pinna is pulled and the tragus is pushed gently to see whether pain is worsened.
The ear canal is inspected with an otoscope; the character of discharge and presence of canal lesions, granulation tissue, or foreign body are noted. Edema and discharge may block visualization of all but the distal canal (irrigation should not be used in case there is a tympanic membrane perforation), but when possible, the tympanic membrane is inspected for inflammation, perforation, distortion, and signs of cholesteatoma (eg, canal debris, polypoid mass from tympanic membrane).
When the ear canal is severely swollen at the meatus (eg, as with severe otitis externa) or there is copious drainage, careful suctioning can permit an adequate examination and also allow treatment (eg, application of drops, with or without a wick).
The cranial nerves are tested.
The nasal mucosa is examined for raised, granular lesions, and the skin is inspected for vasculitic lesions, both of which may suggest granulomatosis with polyangiitis.
Red flags
The following findings are of particular concern:
Recent major head trauma
Any cranial nerve dysfunction (including sensorineural hearing loss or acute vertigo)
Fever
Erythema of ear or periauricular tissue
Diabetes or immunodeficiency
Interpretation of findings
Otoscopic examination can usually diagnose perforated tympanic membrane, otitis media, foreign body, or other uncomplicated sources of otorrhea. Some findings are highly suggestive (see table Some Causes of Ear Discharge). Other findings are less specific but indicate a more serious problem that involves more than a localized external ear or middle ear disorder:
Vertigo and tinnitus (disorder of the inner ear)
Cranial nerve deficits (disorder involving the skull base, such as infection or tumor)
Erythema and tenderness of the ear, surrounding tissues, or both (significant infection)
Testing
Many causes of ear discharge are clear after history and physical examination.
If cerebrospinal fluid (CSF) leakage is in question, discharge can be tested for glucose or beta-2 transferrin; these substances are present in CSF but not in other types of discharge.
Patients without an obvious etiology on examination require audiogram and computed tomography (CT) of the temporal bone or gadolinium-enhanced magnetic resonance imaging (MRI). When ear canal granulation tissue is present, biopsy should be considered if history and physical examination and CT are not clearly consistent with cholesteatoma.
Treatment of Otorrhea
Treatment is directed at the cause of the ear discharge. Sometimes a wick is placed to allow antibiotics to get into a very swollen ear canal (eg, with severe otitis externa). If there is a strong suspicion of chronic CSF leak, pneumococcal vaccine should be administered. Most physicians do not treat a suspected CSF leak with antibiotics without a definitive diagnosis because antibiotics might mask the onset of meningitis. Tympanoplasty can be performed to prevent chronic drainage through a perforation. It is recommended that CSF leaks are repaired to reduce the risk of meningitis.
Key Points
Acute discharge in a patient without chronic ear problems or immunodeficiency is likely the result of otitis externa or perforated otitis media.
Severe otitis externa may require specialty referral for more extensive cleaning and possible wick placement.
Patients with chronic or recurrent ear symptoms (diagnosed or undiagnosed), cranial nerve findings, or systemic symptoms should have specialty referral.
