Ear discharge (otorrhoea)

Question 1

Probability diagnosis

Answer 1

Acute otitis media with perforation

Chronic suppurative otitis media

Furuncle (boil) of ear canal

Infected otitis externa

Reactive skin conditions e.g. eczema

Liquified wax

Question 2

Serious disorders not to be missed

Answer 2

Infection:

• Pseudomonas pyocyanea
• Cholesteatoma
• Herpes zoster oticus
• Mastoiditis

Cancer:

• Malignancy with discharge e.g. SCC

Other:

• Cerebrospinal fluid otorrhoea (fractured temporal bone)
• Necrotising otitis media

Question 3

Pitfalls (often missed)

Answer 3

Foreign body with infection/liquidisation e.g. insects

Trauma ± blood

Rarities:

• Keratitis obliterans
• Branchial or salivary fistula
• Wegener’s granulomatosis

Question 4

Is the patient trying to tell me something?

Answer 4

Factitious? Consider excessive manipulation of ear canal

Question 5

Key history

Answer 5

Nature of discharge:

• acute or chronic
• clear or bloody
• offensive

Associated symptoms:

• pain in ear or adjacent structures
• fever
• tinnitus
• dizziness/vertigo
• hearing loss

Use of ear drops and ear toilet

Previous history of ear problems and ear surgery

History of water sports, air travel, tropical residence or head injury

Question 6

Key examination

Answer 6

Look for cause:

Otoscopic view of ear and canal

Inspection of surrounding structures e.g. mastoid

Look for evidence of herpes zoster infection (sensory branch 7th cranial nerve)

Question 7

Comparison of types of discharge

Answer 7

Unsafe Safe

Source Cholesteatoma Mucosa

Odour Foul Inoffensive

Amount Usually scant, never profuse Can be profuse

Nature Purulent Mucopurulent

If an attic perforation is recognised or suspected, specialist referral is essential.

• Cholesteatoma cannot be eradicated by medical means.

Question 8

Key investigations

Answer 8

First line:

• swab for M & C of ear discharge
• simple bedside hearing tests

Consider:

• X-ray mastoid
• audiometry
• wound swabs (if evidence infection)
• duplex ultrasound
• ankle brachial index
• biopsy
• KFTs

Question 9

Diagnostic tips

Answer 9

Acute ear discharge is most likely due to otitis externa or perforated ear drum with otitis media.

Question 10

Infected ear: unsafe perforation

Answer 10

Question 11

Infected ear: safe perforation

Answer 11