EAR DISCHARGE
Calma.Capili.Coruña.Dagang.
Datukon.Dayrit.De Castro.De La Llana
Ear Discharge
• Drainage of fluid, blood, cerumen, or pus from
the ear
• May be caused by a minor ear irritation or an
infection
• Also called OTORRHEA
Types/Quality of Ear Discharge
Color
Viscosity
Odor
Serous
(clear/watery)
Bloody
Purulent
(yellow-brown)
Thick
Foul smelling
Thin
Odorless
Associated Signs and Symptoms
SIGNS and SYMPTOMS
Ear pain or otalgia
Ear swelling
Ear pruritus
Vertigo
Tinnitus
Hearing loss
Differential Diagnoses
• Is it acute or chronic?
– Acute: < 6 weeks
– Chronic: ≥ 6 weeks
ACUTE EAR DISCHARGE
Cause
Suggestive Findings
Acute otitis
media with
perforated TM
Chronic otitis
media
Severe pain, with relief on
appearance of purulent
discharge
Otorrhea in patients with
chronic perforation,
sometimes with
cholesteatoma
Can also manifest as chronic
discharge
Diagnostic
Approach
Clinical
evaluation
Clinical
evaluation;
sometimes
high-resolution
temporal bone
CT
Pathophysiology: Otitis Media
• Obstruction of the eustachian tube appears to be
the most important antecedent event associated
with AOM
• Physiologic functions of the eustachian are as
follows:
– Ventilation or pressure regulation of the middle ear
– Protection of the middle ear from nasopharyngeal
secretions and sound pressures
– Clearance or drainage of middle ear secretions into
the nasopharynx
Otitis Media
URTI
Inflammation of the nasopharynx extending to the eustachian tube
Stasis and inflammation within the eustachian tube
Altered pressures within the middle ear (negative, related to ambient pressure)
Acute inflammatory reaction: vasodilatation, exudation, leukocyte invasion, phagocytosis, and
local immunological responses within the middle ear cleft
ACUTE EAR DISCHARGE
Cause
Suggestive Findings
Diagnostic
Approach
CSF leak from Significant, clinically obvious Cranial CT,
head trauma head injury or recent surgery including skull
base
Fluid ranges from crystal
clear to pure blood
PostAfter tympanostomy tube
Clinical
tympanostomy placement
evaluation
tube
May occur with water
exposure
ACUTE EAR DISCHARGE
Cause
Otitis externa
(infectious or
allergic)
Suggestive Findings
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 infectious
Typically involvement of earlobe,
where drops trickled out of ear canal
Both: Canal very edematous,
inflamed, with debris; normal TM
Diagnostic
Approach
Clinical
evaluation
CHRONIC EAR DISCHARGE
Cause
Suggestive Findings
Diagnostic
Approach
Cancer of ear Discharge often bloody, mild Biopsy, CT scan,
canal
pain
MRI in selected
cases
Sometimes visible lesion in
canal
Easy to confuse with otitis
externa early on
Cholesteatoma History of TM perforation
CT scan,
culture, MRI if
Flaky debris in ear canal,
intracranial
pocket in TM filled with
extension
caseous debris, sometimes
suspected
polypoid mass
CHRONIC EAR DISCHARGE
Cause
Suggestive Findings
Diagnostic
Approach
Chronic
Long history of ear infections Clinical
purulent otitis or other ear disorders
evaluation
media
Less pain than with external Usually culture
otitis
Canal macerated,
granulation tissue, TM
immobile, distorted, usually
visible perforation
CHRONIC EAR DISCHARGE
Cause
Suggestive Findings
Foreign body
Usually in children
Drainage foul-smelling,
purulent
Foreign body often visible on
examination unless marked
edema or drainage
Mastoiditis
Fever, history of untreated or
unresolved otitis media
Redness, tenderness over
mastoid
Diagnostic
Approach
Clinical
evaluation
Clinical
evaluation,
culture,
sometimes CT
CHRONIC EAR DISCHARGE
Cause
Necrotizing
otitis externa
Suggestive Findings
Usually history of immune
deficiency or diabetes
Chronic severe pain
Periauricular swelling and
tenderness, granulation
tissue in ear canal
Sometimes facial nerve
paralysis
Diagnostic
Approach
CT scan or MRI
Culture
CHRONIC EAR DISCHARGE
Cause
Wegener’s
granulomatosis
Suggestive Findings
Often with respiratory tract
symptoms, chronic
rhinorrhea, arthralgias, and
oral ulcers
Diagnostic
Approach
Urinalysis
Chest x-ray
Antineutrophilic
cytoplasmic
antibody testing
Biopsy
Causes of Otorrhea
Causes of Otorrhea
Diagnostics
Otitis Media
• The diagnosis is made otoscopically revealing
an opaque, thickened, erythematous and
sometimes bulging tympanic membrane.
• The tympanic membrane is immobile by
pneumatic otoscopy
Otitis Media with Effusion
• Otoscopically, the tympanic membrane often
appears opaque, thickened and occasionally
retracted
• Color may be pale, reddish, yellowish or bluish
depending on the effusion
• Tympanogram
– A graphic record of tympanic membrane mobility
will show a flat curve (type B) or occasionally a
negative-pressure peak (type C) in mild and acute
cases
Chronic Suppurative Otitis Media
• Otoscopic examination will reveal a central
perforation in the tympanic membrane that
does not involve the fibrocartilaginous ring
– Often appreciated only in a dry ear
– Valsalva maneuver may cause air bubbles to
appear in the secretions
• Smear , culture and sensitivity
– Not routinely done except for severely resistant
infections
• Imaging studies
– Not routinely done
– May be useful for diagnosing mastoiditis
Management
Otitis Externa
• Acidification of ear canal with drops
– Reduced pH retards antibiotic growth
– Acetic acid
• +/- topical antibiotics
– Treats bacterial infection and reduces edema
– Polymyxin B, neomycin and hydrocortisone; ciprofloxacin;
ofloxacin (bacterial growth)
– Nystatin powder (fungal infections)
Otitis Externa
• EarSol HC, VoSoL HC, Acetasol HC
– Treats superficial bacterial infections of the EAC
• Neomycin, polymyxin B, and hydrocortisone
– for steroid-responsive inflammatory condition for which a
corticosteroid is indicated and where bacterial infection or
a risk of bacterial infection exists.
• Ciprofloxacin / Ofloxacin
– Inhibits bacterial growth by inhibiting DNA gyrase
• Nystatin powder
– Fungicidal and fungistatic antibiotic
Administer until 48 H after disappearance of symptoms.
– 1-2 puffs from handheld nebulizer for 1 wk administered
by treating physician
Otitis Externa
• Further Outpatient Care
Suctioning of the external auditory canal on a weekly
basis until debris has been removed. Topical eardrops are the
mainstay of both inpatient and outpatient treatment. Oral
antibiotics or antifungal agents are usually reserved for
refractory cases.
• Prevention
Otitis externa can be prevented by avoiding use of
cotton-tipped swabs or objects such as bobby pins to clean
ears. Use of cotton-tipped swabs or bobby pins can cause
excoriation of the canal skin that can lead to otitis externa.
CSOM
• Medical Treatment
– aim is to eliminate infection and to control otorrhea
– topical liquid agents used in the treatment of chronic
middle ear disease include (combination of
antibiotics, antifungals, antiseptics, solvents, and
steroids)
– The most commonly used topical antibiotics for CSOM
include quinolones and aminoglycosides
– Oral antibiotics should be prescribed to patients with
severe infections & to those who are systemically ill
CSOM
• Medical treatment should be accompanied by aural
toilet.
• Principal aim of surgery for chronic suppurative otitis
media
– to clear out the disease
– if possible, to reconstruct the patient's hearing
• General indications for surgery are as follows:
– Perforation that persists beyond 6 weeks
– Otorrhea that persists for longer than 6 weeks despite
antibiotic use
– Cholesteatoma formation
– Radiographic evidence of chronic mastoiditis, such as
coalescent mastoiditis
– Conductive hearing loss
CSOM
• Tympanoplasty
– Goal: to eradicate disease from the middle ear
and to reconstruct the hearing mechanism, with
or without grafting of the tympanic membrane
– 2 primary types:
• lateral graft technique - the graft material is laid
laterally to the annulus after the remnant of squamous
tissue is denuded.
• medial grafting - the annulus is raised and the graft
slipped medially
CSOM w/o Cholesteatoma
• Myringoplasty - operation specifically designed to close
tympanic membrane defects.
• Tympanoplasty
• Mastoidectomy
– removal of the outer wall of the mastoid cortex and the
exteriorization of all the mastoid air cells. This may be
performed immediately in coalescent mastoiditis, in which
case a drain may be left postoperatively.
Canal wall-up mastoidectomy - removal of mastoid air cells
while retaining the posterior canal wall. This is also the
common approach for cochlear implantation.
CSOM w/ Cholesteatoma
• Mastoidectomy
Modified radical mastoidectomy - the ossicles and the
tympanic membrane remnants are preserved for
possible hearing reconstruction
Radical mastoidectomy - eradication of all disease from
the middle ear and the mastoid and exteriorization of
these structures into a single cavity; includes
removing the entire tympanic membrane and the
ossicles (except the stapes footplate) and closing the
eustachian tube opening.
AOM
• Medical Management
– Mostly viral in origin, especially those that accompany
coryza. Most common: RSV, influenza viruses,
adenovirus, and parainfluenza
– Treatment is purely symptomatic and supportive
– High doses of amoxicillin - result in middle ear fluid
levels that exceed the minimum inhibitory
concentration of all S pneumoniae
AOM
• Erythromycin
– Has an antibacterial spectrum similar but not identical
to that of penicillin; alternative for patients who are
allergic to penicillin.
• Penicillin G benzathine
– Remains a useful antibiotic but is inactivated by
bacterial beta-lactamases. Parenteral therapy with
benzylpenicillin is used initially in severe infections,
followed by 3-7 days of oral Penicillin V
AOM
• Gentamicin with hydrocortisone
– Aminoglycosides although commonly used topical
antibiotics, controversy surrounds topical therapy because
of its potential for ototoxicity. Literature contains sporadic
reports of sensorineural hearing loss associated w/ use
• Ciprofloxacin
– Quinolone derivatives have excellent antipseudomonal
activity. Inhibits bacterial DNA synthesis & growth. Also
available as ototopical preparations, w/ little demonstrable
systemic effects.
AOM
• Medical Management
– Pain control is essential to treatment, especially in
the first 24 hours after diagnosis, since pediatric
population is often undertreated for pain. In
addition to ibuprofen and acetaminophen, topical
benzocaine can also be given for pain control.
Guidelines also include the use of narcotic
analgesia with codeine for severe pain.
AOM
• Surgical Management
– Myringotomy - an incision is made in the tympanic
membrane to adequately drain the middle ear;
reserved for AOM associated with severe otalgia
or high fever in patients who have had a poor
response to antibiotics.
– Recurrent AOM in children may be due to chronic
sinus infections, nasopharyngeal obstruction, or
cleft palate. Surgically treating these conditions
may decrease the number of ear infections.
Foreign Body
• Irrigation - simplest method, provided the tympanic
membrane is not perforated. Irrigation w/ water is
contraindicated for soft objects, organic matter, or
seeds, w/c may swell
• Suction - sometimes a useful. Suction the ear with a
small catheter held in contact with the object. Grasp
the object with alligator forceps. Place a right-angled
hook behind the object and pull it out. Form a hook
with a 25-gauge needle to snag and remove a large,
soft object such as an eraser.
• Avoid any interventions that push the object in deeper.
Foreign Body
• Cyanoacrylate adhesives (eg, Superglue) may
be removed manually within 24-48 hours once
desquamation occurs. If adhesive touches the
tympanic membrane, remove it carefully and
reevaluate
• Remove batteries immediately to prevent
corrosion or burns. Do not crush battery
during removal
Cancer of the Ear Canal
• Medical Management
– Primary radiation is ineffective for curative treatment
– For cases in which contraindications to surgery are serious
deterrents to surgery, palliative radiation and
chemotherapy may be offered
– Most authors advocate full course postoperative radiation
to stage T3 or T4 tumors as defined by the University of
Pittsburgh staging system
– Literature supports a beneficial effect of postoperative
radiation on survival. The temporal bone and neck should
be treated with 50-60 Gy for tumors staged T3 and T4.
Radiation may also be indicated for smaller lesions.
Cancer of the Ear Canal
• Surgical
– all patients who are medically able should undergo surgical
treatment
– optimal surgery removes all of the cancer en bloc because
positive margins are associated with poor survival rates
– The resection procedures that can be performed for the
temporal bone include:
modified lateral temporal bone resection
lateral temporal bone resection
subtotal temporal bone resection
total temporal bone resection.
Cancer of the Ear Canal
• Surgical
– Adjunctive surgical procedures - neck dissection,
parotidectomy, and craniotomy, should be performed
when indicated
– Advanced tumors with intracranial invasion - palliation
with less extensive (and less morbid) surgical procedures.
Wegener’s Granulomatosis
• Manage the primary condition
– Immunosuppression
– IVIG
– Plasmapheresis
• wTucci, D. Otorrhea in
http://ww.merck.com/mmpe/sec08/ch084/ch
084c.html. January 2009. Accessed September
16, 2009.
• Causes of Otorrhea in
http://www.ncbi.nlm.nih.gov/bookshelf/br.fcg
i?book=cm&part=A3683&rendertype=table&i
d=A3692. 1990. Accessed September 16,
2009.