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Otorrhea

By

David M. Kaylie

, MS, MD, Duke University Medical Center

Last full review/revision Mar 2019| Content last modified Mar 2019
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Topic Resources

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 Some Causes of Ear Discharge).

Overall, the most common causes are

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

Table
icon

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

Otorrhea in patients with chronic perforation, sometimes with cholesteatoma

Can also manifest as chronic discharge

Clinical evaluation

Sometimes high-resolution temporal bone CT

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

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 debris in ear canal, pocket in TM filled with caseous debris

Sometimes polypoid mass or granulation tissue over the cholesteatoma

CT

Culture

(No use for MRI unless intracranial extension is suspected)

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

Usually in children

Drainage foul-smelling, purulent

Foreign body often visible on examination unless marked edema or drainage

Clinical evaluation

Often fever, history of untreated or unresolved otitis media

Redness, tenderness over mastoid

Clinical evaluation

Culture

Usually CT

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

Granulomatosis with polyangiitis (formerly Wegener granulomatosis)

Often with respiratory tract symptoms, chronic rhinorrhea, arthralgias, and oral ulcers

Urinalysis

Chest x-ray

Antineutrophilic cytoplasmic antibody testing

Biopsy

*< 6 weeks

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 cerebrospinal fluid (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.

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 granulomatosis with polyangiitis.

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 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. When auditory canal granulation is present, biopsy should be considered if clinical evaluation and CT are not clearly consistent with cholesteatoma.

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.

  • Patients with chronic or recurrent ear symptoms (diagnosed or undiagnosed), cranial nerve findings, or systemic symptoms should have specialty referral.

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