Ear discharge

Ear discharge (otorrhoea) is fluid draining from the external canal. It originates from the canal skin, the middle ear through a perforation or grommet, the mastoid, or the intracranial space (CSF).

Clinical relevance. Persistent or recurrent discharge usually means chronic otitis media with perforation. Cholesteatoma erodes bone and can lead to facial palsy, labyrinthine fistula, meningitis and brain abscess. Blood stained discharge from a polyp or granulation in an adult needs biopsy to exclude cancer.

Classification by character.

• Purulent (infection), mucoid (middle ear origin), serous or watery (eczema, early infection, barotrauma), serosanguinous (granulation, early tumour, trauma), bloody (trauma, tumour, glomus, bullous myringitis), clear and watery after head injury (CSF), black or fluffy debris (otomycosis), foul smelling (cholesteatoma, anaerobes).

Classification by duration. Acute (under 6 weeks), chronic (over 6 weeks to 3 months, often the working definition of chronic suppurative otitis media).

Classification of chronic otitis media. Mucosal (tubotympanic) disease with a central perforation and intermittent mucoid discharge; squamous (atticoantral) disease with an attic or marginal perforation, retraction pocket, keratin debris and cholesteatoma, which is the dangerous form.

Key distinctions. Pain suggests otitis externa, acute otitis media or malignant otitis externa. Painless chronic discharge suggests chronic suppurative otitis media or tuberculous otitis media. A halo sign on blotting paper and a clear watery discharge after head injury suggest CSF.

History.

• Onset, duration, character and volume, side, odour, blood stain.
• Pain, itch, hearing loss, tinnitus, vertigo, facial weakness, headache, fever.
• Previous episodes, previous ear surgery or grommets.
• Trauma (cotton buds, head injury), swimming or water exposure, hearing aid or earplug use.
• Skin conditions (eczema, seborrhoeic dermatitis, psoriasis).
• Recent flying or diving, and use of ear drops.

Background. Diabetes, immunosuppression, HIV, cancer, previous radiotherapy, tuberculosis contact, sinus disease, granulomatosis symptoms, craniofacial anomalies and cleft palate.

Examination.

• Inspect the pinna and post-auricular area for swelling, protrusion, tenderness, and sinus tracts.
• Clean the canal by gentle dry mopping or microsuction, with microscopy when available, to show the source: canal skin (swollen, eczematous, fungal debris, furuncle, polyp), tympanic membrane (central or marginal or attic perforation, retraction pocket, keratin debris, granulation, polyp, grommet position).
• Tuning forks and whispered voice for hearing; facial nerve; other cranial nerves; fistula sign (pneumatic otoscopy provoking vertigo or nystagmus); nystagmus; neck and mastoid.
• Nasopharynx and oropharynx; palate; nasal examination.
• Neurological examination, fundi and meningism when intracranial complications are suspected.

Red flags

• Pain out of proportion, swollen canal, granulation at the canal floor, diabetes or immunosuppression (malignant otitis externa)
• Post-auricular swelling, protruding pinna, fever, or systemic upset (mastoiditis)
• Facial weakness, vertigo, sudden hearing loss
• Headache, drowsiness, neck stiffness, seizure, diplopia or abducens palsy with retro-orbital pain (Gradenigo syndrome), or focal deficit
• Clear watery discharge after head injury, or discharge with a skull base fracture
• Blood stained discharge, polyp or granulation in an adult, or a mass
• Multiple perforations with painless discharge (tuberculosis or vasculitis)
• Persistent discharge after 6 to 12 weeks of treatment
• Foul discharge with keratin debris (cholesteatoma)
• Button battery or other foreign body in the canal

Special groups. Children: acute otitis media with perforation, grommet otorrhoea, foreign body, and chronic suppurative otitis media (which causes persistent conductive loss and developmental effects). Pregnancy: avoid oral ciprofloxacin and doxycycline; topical therapy is acceptable. Diabetes and immunosuppression: low threshold for malignant otitis externa. Region specific: chronic suppurative otitis media is common where primary care is limited, and tuberculous otitis media, otomycosis and HIV related disease occur.

Outer ear

• Acute diffuse otitis externa, chronic otitis externa, furuncle
• Eczema, seborrhoeic dermatitis, contact dermatitis (topical drops, hearing aids)
• Otomycosis (Aspergillus, Candida)
• Malignant (necrotising) otitis externa
• Foreign body (including button battery and insects)
• Herpes zoster oticus
• Canal cholesteatoma, keratosis obturans
• Squamous cell carcinoma and basal cell carcinoma of the canal

Middle ear and mastoid

• Acute otitis media with perforation
• Chronic suppurative otitis media (mucosal disease)
• Cholesteatoma (squamous disease)
• Grommet otorrhoea, post-surgical otorrhoea
• Acute and chronic mastoiditis, petrous apicitis
• Tuberculous otitis media
• Aural polyp (inflammatory, granulation tissue)
• Glomus tumour, middle ear carcinoma

Systemic and inflammatory

• Granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis, sarcoidosis
• Langerhans cell histiocytosis, lymphoma, leukaemic infiltration
• Syphilis

Intracranial and skull base

• CSF otorrhoea after head trauma, from a tegmen defect or after surgery
• Intracranial complications of chronic otitis media: meningitis, extradural abscess, subdural empyema, brain abscess, lateral sinus thrombosis, otitic hydrocephalus
• Labyrinthitis and facial nerve palsy

Other

• Barotrauma with bleeding, bullous myringitis
• Trauma to the canal or drum, temporal bone fracture
• Ruptured sebaceous cyst or infected pre-auricular sinus

Reasoning. Clean the canal, find the source, and decide on swab, biopsy and imaging by duration, pain, risk factors and complication signs.

First line. Otoscopy with suction toilet, tuning forks, temperature, blood pressure, glucose, facial nerve and cranial nerve examination, and audiometry (an air bone gap confirms conductive loss; a sensorineural component suggests labyrinthine involvement).

Swab. Culture and sensitivity from the canal for chronic or recurrent discharge, treatment failure, diabetes or immunosuppression. Fungal microscopy and culture when debris is fluffy or black. Swab for varicella zoster PCR from vesicles. Request acid fast bacilli smear, culture and PCR when tuberculosis is suspected (painless discharge, multiple perforations, pale granulation).

Biopsy. Any aural polyp or granulation in an adult, and any persistent canal lesion, with histology and cultures for malignancy, granulomatosis with polyangiitis, tuberculosis and Langerhans cell histiocytosis.

Imaging

• High resolution CT temporal bone with contrast for chronic discharge with suspected cholesteatoma, suspected complications, malignant otitis externa, or before surgery (shows erosion of the scutum, ossicles, tegmen and facial canal).
• MRI brain and temporal bones with gadolinium and diffusion weighted sequences for intracranial complications, lateral sinus thrombosis (with venography), cholesteatoma recurrence and skull base involvement. Technetium or gallium scans for malignant otitis externa when MRI is not decisive.
• CT head and temporal bone with fine cuts for CSF leak.

CSF otorrhoea. Collect fluid for beta-2 transferrin (highly sensitive and specific; needs only a small volume). Glucose in the fluid alone is unreliable.

Blood tests. Full blood count, C reactive protein, ESR, glucose and HbA1c, urea and creatinine, and cultures when febrile. ANCA, antinuclear antibody, angiotensin converting enzyme and urinalysis when vasculitis or sarcoidosis is suspected; HIV and syphilis serology; interferon gamma release assay or tuberculin test and chest radiograph when tuberculosis is suspected.

Limitations. Swab cultures from the canal may grow colonising organisms and do not always reflect the middle ear. A normal CT does not exclude early cholesteatoma. Beta-2 transferrin can be falsely positive in liver disease and with vitreous fluid.

Emergency conditions

• Intracranial complications and suspected bacterial meningitis:
  • ceftriaxone 2 g IV every 12 hours with metronidazole 500 mg IV every 8 hours
  • add vancomycin by a loading dose of 25 to 30 mg/kg IV, maximum 3 g, then 15 to 20 mg/kg every 8 to 12 hours adjusted to creatinine clearance and levels, when resistant organisms are possible
  • dexamethasone 10 mg IV every 6 hours for 4 days with the first dose before or with the antibiotic for meningitis
  • neurosurgical and ENT review for drainage
• Mastoiditis: admit; ceftriaxone 2 g IV daily (children 50 to 80 mg/kg IV once daily, maximum 2 g) with metronidazole 500 mg IV every 8 hours when chronic disease or cholesteatoma is likely.
• Mastoiditis also needs CT, and ENT surgery for abscess or failure to respond in 24 to 48 hours.
• Malignant otitis externa: admit; ceftazidime 2 g IV every 8 hours or ciprofloxacin 400 mg IV every 8 to 12 hours initially.
• Then oral ciprofloxacin 750 mg twice daily (adjust for creatinine clearance; QT and tendon warnings) for a minimum of 6 weeks, with glycaemic control and ENT surgical review.
• Lateral sinus thrombosis: IV antibiotics with ceftriaxone and metronidazole at the doses given for intracranial complications, anticoagulation by specialist decision (enoxaparin 1 mg/kg subcutaneously every 12 hours, adjusted when creatinine clearance is under 30 mL/min), and urgent ENT surgery.
• Button battery in the canal: remove immediately under direct vision; do not irrigate; ENT referral.
• CSF otorrhoea: raise the head of the bed to 30 degrees, avoid straining, nose blowing and sneezing with the mouth closed, and refer urgently to ENT and neurosurgery.
• Prophylactic antibiotics are debated and are decided by the specialist.
• If meningitis is suspected, give ceftriaxone 2 g IV every 12 hours with dexamethasone 10 mg IV every 6 hours for 4 days.

Aural toilet (all patients). Suction or gentle dry mopping by a trained clinician, then keep the ear dry: no swimming, a petroleum jelly coated cotton wool ball or earplug during bathing, no cotton buds, no irrigation with a perforation, grommet or previous ear surgery.

Otitis externa

• Ciprofloxacin 0.3 percent with dexamethasone 0.1 percent ear drops, 4 drops into the canal twice daily for 7 days (safe with a perforated drum). Acetic acid 2 percent spray or drops, 5 drops three times daily for 7 days for mild disease with an intact drum. Avoid neomycin, framycetin and gentamicin containing drops with a perforation.
• Swollen canal: insert a wick for 2 to 3 days and use drops through it.
• Systemic antibiotics only for cellulitis beyond the canal, systemic illness, diabetes or immunosuppression: flucloxacillin 500 mg to 1 g orally four times daily for 7 days (clarithromycin 500 mg orally twice daily in penicillin allergy).
• Eczematous or seborrhoeic canal: hydrocortisone 1 percent ointment or cream applied thinly to canal skin twice daily for 7 days, and treat the skin disease.

Otomycosis. Thorough debris removal and clotrimazole 1 percent solution, 4 drops three times daily for at least 14 days (evidence is limited; treat predisposing factors such as prolonged antibiotic drops and moisture). Refractory cases: ENT review.

Acute otitis media with perforation. Analgesia and antibiotics:

• adults: amoxicillin 500 mg orally three times daily for 5 to 7 days (maximum 3 g daily), with clarithromycin 500 mg twice daily in penicillin allergy
• children: amoxicillin 40 to 90 mg/kg daily in 2 or 3 divided doses (maximum 3 g daily) for 5 to 10 days

Topical ciprofloxacin 0.3 percent drops 4 drops twice daily for 7 days for persistent discharge. Most perforations heal within 6 weeks; review at 6 weeks and refer if open at 3 months.

Chronic suppurative otitis media (mucosal disease)

• Aural toilet and topical ciprofloxacin 0.3 percent ear drops, 4 drops twice daily for 7 to 14 days (prolonged use risks fungal overgrowth). Review at 2 weeks.
• Systemic antibiotics are not first line; use ciprofloxacin 500 mg orally twice daily for 7 days (adjust to creatinine clearance, avoid in pregnancy and in children unless essential) for acute exacerbation with cellulitis.
• Tympanoplasty or myringoplasty by ENT once the ear has been dry for several weeks. Avoid repeated courses of drops without ENT assessment.

Cholesteatoma and persistent discharge. ENT referral for mastoid and middle ear surgery. Aural toilet and topical therapy only as a bridge.

Grommet otorrhoea. Ciprofloxacin 0.3 percent with dexamethasone 0.1 percent drops, 4 drops twice daily for 5 to 7 days; no water entry; review at 2 weeks for persistent discharge and consider removal.

Foreign body. Removal under direct vision by a trained clinician. Kill live insects with olive oil or lidocaine drops first. Avoid irrigation of vegetable matter.

Aural polyp, mass and granulation. Biopsy and ENT referral.

Tuberculous otitis media. Isoniazid 5 mg/kg (maximum 300 mg), rifampicin 10 mg/kg (maximum 600 mg), pyrazinamide 25 mg/kg (maximum 2 g) and ethambutol 15 mg/kg orally daily for 2 months, then isoniazid and rifampicin for 4 months (6 months in total).

Give pyridoxine 10 to 25 mg daily, with baseline and monthly liver function, and visual acuity and colour vision monitoring for ethambutol. Specialist infectious disease care.

Granulomatosis with polyangiitis and other systemic causes. Specialist rheumatology: prednisolone 1 mg/kg orally daily (maximum 60 to 80 mg) with rituximab or cyclophosphamide.

Ramsay Hunt syndrome. Valaciclovir 1 g orally three times daily for 7 days with prednisolone 1 mg/kg orally daily (maximum 60 mg) for 7 days then reduced over 7 days, started within 72 hours.

Adjust valaciclovir to creatinine clearance (30 to 49 mL/min, 1 g every 12 hours; 15 to 29 mL/min, 1 g daily; under 15 mL/min, 500 mg daily).

Malignancy. Urgent referral to head and neck oncology with biopsy, imaging and staging.

Monitoring. Review in 1 to 2 weeks to confirm a dry ear, repeat audiometry after resolution, repeat swab if persistent, glucose in diabetes, ototopical therapy duration, and healing of any perforation by 6 weeks to 3 months.

Referral and escalation. Same day: suspected malignant otitis externa, mastoiditis, intracranial complications, facial palsy with discharge, CSF leak, button battery. Urgent within 2 weeks: aural polyp or granulation in adults, suspected cholesteatoma or tumour, and systemic disease features. ENT for any discharge persisting beyond 6 weeks, recurrent discharge, or perforation that does not heal. Audiology for hearing loss.

Admission criteria. Malignant otitis externa, mastoiditis, suspected intracranial complication, CSF leak, immunocompromised patient with severe infection, systemic illness, or inability to maintain treatment at home.

Discharge and safety netting. Keep the ear dry. Return for post-auricular swelling, fever, headache, vomiting, neck stiffness, drowsiness, facial weakness, vertigo, new hearing loss, severe pain, clear watery discharge after head injury, or discharge persisting beyond 2 weeks after treatment.