Ear Discharge: A Merck Manual of Patient Symptoms podcast

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

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 Table 2: Approach to the Patient With Ear Problems: Some Causes of Ear Discharge).

Overall, the most common causes are

• Acute otitis media with perforation
• Chronic otitis media (with a perforation of the eardrum, cholesteatoma, or both)
• Otitis externa

The most serious causes are necrotizing external otitis and cancer of the ear.

Table 2
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Some Causes of Ear Discharge Cause Suggestive Findings Diagnostic Approach Acute discharge* Acute otitis media with perforated TM Severe pain, with relief on appearance of purulent discharge Clinical evaluation Chronic otitis media Otorrhea in patients with chronic perforation, sometimes with cholesteatoma Can also manifest as chronic discharge Clinical evaluation Sometimes high-resolution temporal bone CT CSF leak caused by head trauma Significant, clinically obvious head injury or recent surgery Fluid ranges from crystal clear to pure blood Head CT, including skull base 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: 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 Clinical evaluation Post-tympanostomy tube After tympanostomy tube placement May occur with water exposure Clinical evaluation Chronic discharge Cancer of ear canal Discharge often bloody, mild pain Sometimes visible lesion in canal Easy to confuse with otitis externa early on Biopsy CT MRI in some cases Cholesteatoma History of TM perforation Flaky debris in ear canal, pocket in TM filled with caseous debris, sometimes polypoid mass CT Culture (No use for MRI unless intracranial extension is suspected) Chronic purulent otitis media 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 Clinical evaluation Usually culture Foreign body Usually in children Drainage foul-smelling, purulent Foreign body often visible on examination unless marked edema or drainage Clinical evaluation Mastoiditis Often fever, history of untreated or unresolved otitis media Redness, tenderness over mastoid Clinical evaluation Culture Sometimes CT Necrotizing otitis externa Usually history of immune deficiency or diabetes Chronic severe pain Periauricular swelling and tenderness, granulation tissue in ear canal Sometimes facial nerve paralysis CT or MRI Culture Wegener's granulomatosis Often with respiratory tract symptoms, chronic rhinorrhea, arthralgias, and oral ulcers Urinalysis Chest x-ray Antineutrophilic cytoplasmic antibody testing Biopsy *< 6 wk. TM = tympanic membrane. Some Causes of Ear Discharge Cause Suggestive Findings Diagnostic Approach Acute discharge* Acute otitis media with perforated TM Severe pain, with relief on appearance of purulent discharge Clinical evaluation Chronic otitis media Otorrhea in patients with chronic perforation, sometimes with cholesteatoma Can also manifest as chronic discharge Clinical evaluation Sometimes high-resolution temporal bone CT CSF leak caused by head trauma Significant, clinically obvious head injury or recent surgery Fluid ranges from crystal clear to pure blood Head CT, including skull base 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: 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 Clinical evaluation Post-tympanostomy tube After tympanostomy tube placement May occur with water exposure Clinical evaluation Chronic discharge Cancer of ear canal Discharge often bloody, mild pain Sometimes visible lesion in canal Easy to confuse with otitis externa early on Biopsy CT MRI in some cases Cholesteatoma History of TM perforation Flaky debris in ear canal, pocket in TM filled with caseous debris, sometimes polypoid mass CT Culture (No use for MRI unless intracranial extension is suspected) Chronic purulent otitis media 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 Clinical evaluation Usually culture Foreign body Usually in children Drainage foul-smelling, purulent Foreign body often visible on examination unless marked edema or drainage Clinical evaluation Mastoiditis Often fever, history of untreated or unresolved otitis media Redness, tenderness over mastoid Clinical evaluation Culture Sometimes CT Necrotizing otitis externa Usually history of immune deficiency or diabetes Chronic severe pain Periauricular swelling and tenderness, granulation tissue in ear canal Sometimes facial nerve paralysis CT or MRI Culture Wegener's granulomatosis Often with respiratory tract symptoms, chronic rhinorrhea, arthralgias, and oral ulcers Urinalysis Chest x-ray Antineutrophilic cytoplasmic antibody testing Biopsy *< 6 wk. TM = tympanic membrane.

Evaluation

History

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 Wegener's granulomatosis (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 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 Wegener's granulomatosis.

Red flags

The following findings are of particular concern:

• Recent major head trauma
• Any cranial nerve dysfunction (including sensorineural hearing loss)
• Fever
• Erythema of ear or periauricular tissue
• Diabetes or immunodeficiency

Interpretation of findings

Otoscopic examination can usually diagnose perforated TM, external otitis media, foreign body, or other uncomplicated sources of otorrhea. Some findings are highly suggestive (see Table 2: Approach to the Patient With Ear Problems: 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)
• Erythema and tenderness of ear, surrounding tissues, or both (significant infection)

Testing

Many cases are clear after clinical evaluation.

If CSF leakage is in question, discharge can be tested for glucose or β₂-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.

Treatment

Treatment is directed at the cause. Most physicians do not treat a suspected CSF leak with antibiotics without a definitive diagnosis because drugs might mask the onset 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.
• Those with recurrent ear symptoms (diagnosed or undiagnosed), cranial nerve findings, or systemic symptoms should have specialty referral.

Last full review/revision January 2009 by Debara L. Tucci, MD, MS