Ear discharge (otorrhea) is drainage exiting the ear. It may be serous, serosanguineous, or purulent. Associated symptoms may include ear pain, fever, pruritus, vertigo Dizziness and Vertigo Dizziness is an imprecise term patients often use to describe various related sensations, including Faintness (a feeling of impending syncope) Light-headedness Feeling of imbalance or unsteadiness... read more , tinnitus Tinnitus Tinnitus is a noise in the ears. It is experienced by 10 to 15% of the population. Subjective tinnitus is perception of sound in the absence of an acoustic stimulus and is heard only by the... read more , and hearing loss Hearing Loss Worldwide, about half a billion people (almost 8% of the world's population) have hearing loss ( 1). More than 10% of people in the US have some degree of hearing loss that compromises their... read more 
.
Etiology of Otorrhea
Causes of ear discharge 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 Some Causes of Ear Discharge 
).
Overall, the most common causes are
Chronic otitis media Otitis Media (Chronic Suppurative) Chronic suppurative otitis media is a persistent, chronically draining (> 6 weeks), suppurative perforation of the tympanic membrane. Symptoms include painless otorrhea with conductive hearing... read more
(with a perforation of the eardrum, cholesteatoma, or both)
The most serious causes are necrotizing external otitis Mastoiditis Mastoiditis is a bacterial infection of the mastoid air cells, which typically occurs after acute otitis media. Symptoms include redness, tenderness, swelling, and fluctuation over the mastoid... read more and cancer of the ear.
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 (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 Granulomatosis with Polyangiitis (GPA) Granulomatosis with polyangiitis is characterized by necrotizing granulomatous inflammation, small- and medium-sized vessel vasculitis, and focal necrotizing glomerulonephritis, often with crescent... read more 
(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 Granulomatosis with Polyangiitis (GPA) Granulomatosis with polyangiitis is characterized by necrotizing granulomatous inflammation, small- and medium-sized vessel vasculitis, and focal necrotizing glomerulonephritis, often with crescent... read more .
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 Traumatic Perforation of the Tympanic Membrane Traumatic perforation of the tympanic membrane (TM) can cause pain, bleeding, hearing loss, tinnitus, and vertigo. Diagnosis is based on otoscopy. Treatment often is unnecessary. Antibiotics... read more 
, external otitis media External Otitis (Acute) External otitis is an acute infection of the ear canal skin typically caused by bacteria (Pseudomonas is most common). Symptoms include pain, discharge, and hearing loss if the ear canal... read more 
, foreign body External Ear Obstructions The ear canal may be obstructed by cerumen (earwax), a foreign object, or an insect. Itching, pain, and temporary conductive hearing loss may result. Most causes of obstruction are readily apparent... read more , or other uncomplicated sources of otorrhea. Some findings are highly suggestive (see table Some Causes of Ear Discharge 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 of ear discharge are clear after clinical evaluation.
If 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 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 of Otorrhea
Treatment is directed at the cause of the ear discharge. 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.
