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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.
Causes may originate from the ear canal, 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 Some Causes of Ear Discharge).
Overall, the most common causes are
The most serious causes are necrotizing external otitis and cancer of the ear.
Some Causes of Ear Discharge
History of present illness 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 (TM—eg, swimming; insertion of objects, including cotton swabs; use of ear drops). Head trauma sufficient to cause a CSF leak is readily apparent.
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.
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 TM perforation), but when possible, the TM is inspected for inflammation, perforation, distortion, and signs of cholesteatoma (eg, canal debris, polypoid mass from TM).
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.
Otoscopic examination can usually diagnose perforated TM, external otitis media, foreign body, or other uncomplicated sources of otorrhea. Some findings are highly suggestive (see 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:
Many cases are clear after clinical evaluation.
If CSF leakage is in question, discharge can be tested for glucose or β 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 CT of the temporal bone or gadolinium-enhanced MRI. Biopsy should be considered when auditory canal granulation tissue is present.
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 recurrent ear symptoms (diagnosed or undiagnosed), cranial nerve findings, or systemic symptoms should have specialty referral.
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