Otorrhea (Ear Discharge)

Otorrhea (Ear Discharge): Excerpt from In A Page: Pediatric Signs and Symptoms

Otorrhea often arises from the external ear; in the setting of a nonintact tympanic membrane, the middle and even inner ears may be sources as well. Suctioning the otorrhea out of the canal to visualize the tympanic membrane is both therapeutic and diagnostically valuable.

Differential Diagnosis

• Cerumen
  –Often brownish color
  –Rarely associated with otalgia or pruritis

• Otitis externa
  –Bacterial (frequently Pseudomonas and Staphylococcus aureus) vs fungal (especially after prolonged treatment with antibiotic drops)
  –Concern: Necrotizing (malignant) otitis externa (i.e., temporal bone osteomyelitis) in immunosuppressed patients, including brittle diabetics

• Acute otitis media with tympanic membrane (TM) perforation
  –Acute perforation may already have closed by the time the patient is examined
• Chronic perforation drainage
  –From water contamination (swimming, bathing) if patient is not maintaining dry ear precautions (ear plugs, occlusive head bands, shower caps, etc.)
• Tympanostomy tube drainage
  –If bloody, suspect granulation tissue surrounding the tube
  –Increased incidence when not maintaining dry ear precautions is debated (as small tube lumen diameter has considerable surface tension)
• Chronic suppurative otitis media
  –Chronic middle ear and/or mastoid infection with perforated TM
• Cholesteatoma
  –“Skin cyst” (keratinizing stratified squamous epithelium) in the middle ear/mastoid
  –Benign, but often very aggressively locally erosive (mechanical and enzymatic)
  –Surgical, not medical, condition
• Perichondritis
  –Spares the lobule (as there is no cartilage there)
• Myringitis
  –TM granulation or de-epithelialization
• Foreign body
• CSF leak
  –Watery drainage
  –Traumatic or congenital
  –With or without perilymphatic fistula
• Primary dermatologic condition
  –Eczema, psoriasis

Workup and Diagnosis

• History
  –Quality of otorrhea: Malodorous and purulent (infectious) vs bloody (traumatic, granulation tissue) vs clear and watery (CSF)
  –Associated symptoms: Pain and tenderness in acute otitis externa, aural pruritus in chronic or fungal otitis externa
  –Past medical/surgical history: Prior tympanostomy tubes, middle ear surgery (cholesteatoma), trauma or neurosurgery (CSF leak); dermatologic disease

• Physical exam
  –Must suction and debride the ear canal of debris to examine tympanic membrane
  –If canal is too narrow from swelling to see the tympanic membrane, place hydrocellulose wick to draw ototopical medication to affected areas; reexamine in several days
  –Visualize after suctioning (through otoscope) if source is external or middle ear

• Labs
  –Gram stain and culture specimen of otorrhea if diagnosis is in question, if patient is initially systemically symptomatic (febrile or other complications), or if patient fails initial treatment
• Imaging studies
  –CT scan of temporal bone (noncontrast, 1-mm slice thickness) if cholesteatoma or trauma is suspected

Treatment

• Suction and debride the external auditory canal
• Maintain dry ear precautions
  –No water at all allowed within ear canals
• Ototopical antibiotics
  –Unless TM is intact, use nonototoxic (e.g., fluoroquinolone) drops
  –Antifungal solution for candidal infections
• Steroid drops
  –Often a combination product with antibiotic drops
  –Essential if granulation tissue is present
• Reacidification of canal
  –Acetic acid drops
  –Treats both fungal and bacterial infections
  –Painful if TM is not intact
• Oral antibiotic
  –For refractory cases of middle ear etiology
• Prolonged IV antibiotics for severe refractory cases

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

More About Ear conditions

• Back to disease: Ear conditions: Introduction
• Next Book Extract About Ear conditions: Otalgia (Ear Pain) (In A Page: Pediatric Signs and Symptoms)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

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• Otalgia (Ear Pain) (In A Page: Pediatric Signs and Symptoms)
• Hearing Loss – Acquired (In A Page: Pediatric Signs and Symptoms)
• Hearing Loss – Congenital (In A Page: Pediatric Signs and Symptoms)
• EARACHE (Differential Diagnosis in Primary Care)
• AURAL DISCHARGE (OTORRHEA) (Differential Diagnosis in Primary Care)

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