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Ear Discharge

By Debara L. Tucci, MD, MS

Ear discharge (otorrhea) is drainage from the ear. The drainage may be watery, bloody, or thick and whitish, like pus (purulent). Depending on the cause of the discharge, people may also have ear pain, fever, itching, vertigo (see Dizziness and Vertigo), ringing in the ear (tinnitus—see Ear Ringing or Buzzing), and/or hearing loss (see Hearing Loss). Symptoms range from sudden and severe to slowly developing and mild.

Causes

Discharge may originate from the ear canal, the middle ear, or, rarely, from inside the skull.

Overall, the most common causes are

  • Acute (sudden and severe) middle ear infection (otitis media) with perforation (puncture) of the eardrum

  • Chronic otitis media (with perforation of the eardrum, cholesteatoma, or both)

  • External ear infection (otitis externa)

In some people with otitis media (usually children), the eardrum ruptures, releasing the infected material collected behind the eardrum. The hole in the eardrum almost always heals, but sometimes a small perforation remains. A perforation may also result from injury or surgery to the eardrum. When a perforation is present, people are at risk of chronic middle ear infections, which can cause ear discharge.

Serious, but rare, causes include

  • Cancer of the ear canal

  • Fracture of the base of the skull

  • Necrotizing external otitis

  • Cholesteatoma

The ear canal passes through the base of the skull. If a skull fracture (from a severe head injury) involves that part of the skull, blood and/or cerebrospinal fluid may leak from the ear.

Necrotizing, or malignant, external otitis is a particularly severe form of external ear infection that typically occurs only in people with diabetes or those who have a compromised immune system (due to HIV infection or chemotherapy for cancer).

Some people with chronic otitis media develop a noncancerous (benign) growth of skin cells in the middle ear (cholesteatoma) that can cause discharge. Although a cholesteatoma is noncancerous, it can cause significant damage to the ear and nearby structures. In severe cases, a cholesteatoma may lead to deafness, facial weakness or paralysis, and complications with the brain such as an abscess and other infections.

Evaluation

The following information can help people decide when a doctor's evaluation is needed and help them know what to expect during the evaluation.

Warning signs

In people with ear discharge, certain symptoms and characteristics are cause for concern:

  • Recent major head injury

  • Any neurologic symptoms (such as vertigo or difficulty seeing, speaking, swallowing, and/or talking)

  • Hearing loss in the affected ear

  • Fever

  • Redness and/or swelling of the ear or area around the ear

  • Diabetes or a compromised immune system

When to see a doctor

People with warning signs should see a doctor right away. People without warning signs should see a doctor within several days and avoid getting water in the ear until it can be evaluated.

What the doctor does

Doctors first ask questions about the person's symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause of the ear discharge and the tests that may need to be done ( Some Causes and Features of Ear Discharge).

During the medical history, doctors ask about the following:

  • Activities that can affect the ear canal or eardrum (for example, swimming; insertion of objects, including cotton swabs; and use of ear drops)

  • Whether people have had repeated ear infections

  • Any severe head injury

During the physical examination, doctors focus on examining the ears, nose, throat, and neurologic system. By examining the ear canal with a light, doctors can usually diagnose perforated eardrum, external otitis, foreign object, and other common causes of ear discharge. Other findings ( Some Causes and Features of Ear Discharge) suggest the diagnosis.

Some Causes and Features of Ear Discharge

Cause

Common Features*

Tests

Acute discharge (lasting less than 6 weeks)

Acute otitis media with perforated eardrum

Severe ear pain significantly relieved when a thick, whitish discharge starts

A doctor's examination

Chronic otitis media (acute flare up)

History of eardrum perforation and/or cholesteatoma (a noncancerous growth of skin cells in the middle ear), and previous discharge

Eardrum appears abnormal during doctor's examination

A doctor's examination

Sometimes high-resolution temporal bone CT scan

Cerebrospinal fluid leak caused by severe head injury or recent neurosurgery

Obvious recent head injury or neurosurgery

Fluid ranges from crystal clear to blood

Head CT, including skull base

Otitis externa (infectious or allergic)

Infectious : Often after swimming or injury; severe pain, worse with pulling on ear

Allergic : Often after use of ear drops; more itching and redness, and less pain than with infectious cause

Typically a rash on the earlobe, where drops trickled out of ear canal

Both : Ear canal very red, swollen, and filled with debris; eardrum appears normal

A doctor's examination

Chronic discharge (lasting more than 6 weeks)

Cancer of ear canal

Discharge often bloody, mild pain

Sometimes doctor can see a growth in ear canal

Typically in older people

Removal and examination (biopsy) of ear tissue

Usually CT or MRI

Chronic otitis media

History of ear infections and typically eardrum perforation and/or cholesteatoma

Less pain than with external otitis

Eardrum appears abnormal during doctor's examination

A doctor's examination

Usually growth and examination of a sample of the ear discharge (culture)

Foreign object

Usually in children

Drainage foul-smelling, pus-filled (purulent)

Foreign object often visible during examination unless visibility blocked by swelling and/or discharge

A doctor's examination

Mastoiditis

Often fever, history of untreated or unresolved otitis media

Redness, tenderness over mastoid

A doctor's examination

Sometimes CT

Necrotizing external otitis

Usually people have an immune deficiency or diabetes

Chronic severe pain

Swelling and tenderness around ear, abnormal tissue in ear canal

Sometimes weakness of facial muscles on affected side

CT or MRI

*Features include symptoms and the results of the doctor's examination. Features mentioned are typical but not always present.

CT = computed tomography; MRI = magnetic resonance imaging.

Testing

Many causes are clear after the doctor's examination. Possible tests include

  • Audiometry

  • CT or MRI

If the cause is not clear, doctors usually do a formal hearing test (audiometry—see Testing) and computed tomography (CT) or gadolinium-enhanced magnetic resonance imaging (MRI). If abnormal tissue is present in the ear canal, a tissue sample (biopsy) may be taken. Sometimes culture swabs are taken of the drainage to identify infection.

Treatment

Treatment is directed at the cause. People who have a large perforation of the eardrum are advised to keep water out of the ear. People can keep water out of the ear while showering or washing their hair by coating a cotton ball with petroleum jelly and placing it at the opening of the ear canal. Doctors can also make plugs out of silicone and place them in the canal. Such plugs are carefully sized and shaped so that they do not get lodged deep in the ear canal and cannot be removed. People who have a small perforation, such as that caused by a ventilation tube, should ask a doctor whether they need to keep water out of the ear. A cholesteatoma is treated surgically.

Key Points

  • Acute discharge in people without longstanding ear problems or a weakened immune system is usually not dangerous and is typically due to an external ear infection or a perforated eardrum resulting from a middle ear infection.

  • People who have chronic ear symptoms or any symptoms besides ear discharge (particularly any neurologic symptoms) should be evaluated by a specialist.

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* This is the Consumer Version. *