Otorrhea
Otorrhea—drainage from the ear—may be bloody (otorrhagia), purulent, clear, or serosanguineous. Its onset, duration, and severity provide clues to the underlying cause. This sign may result from disorders that affect the external ear canal or the middle ear, including allergy, infection, neoplasms, trauma, and collagen diseases. Otorrhea may occur alone or with other symptoms such as ear pain.
History and physical examination
Begin your evaluation by asking the patient when the otorrhea began, noting how he recognized it. Did he clean the drainage from deep within the ear canal, or did he wipe it from the auricle? Have him describe the color, consistency, and odor of the drainage. Is it clear, purulent, or bloody? Does it occur in one or both ears? Is it continuous or intermittent? If the patient wears cotton in his ear to absorb the drainage, ask how often he changes it.
Then explore associated otologic symptoms, especially pain. Is there tenderness on movement of the pinna or tragus? Ask about vertigo, which is absent in disorders of the external ear canal. Also ask about tinnitus.
Next, check the patient’s medical history for recent upper respiratory infection or head trauma. Also, ask how he cleans his ears and if he’s an avid swimmer. Note a history of cancer, dermatitis, or immunosuppressant therapy.
Focus the physical examination on the patient’s external ear, middle ear, and tympanic membrane. (If his symptoms are unilateral, examine the uninvolved ear first as not to cross-contaminate.) Inspect the external ear, and apply pressure on the tragus and mastoid area to elicit tenderness. Then insert an otoscope, using the largest speculum that will comfortably fit into the ear canal. If necessary, clean cerumen, pus, or other debris from the canal. Observe for edema, erythema, crusts, or polyps. Inspect the tympanic membrane, which should look like a shiny, pearl-gray cone. Note color changes, perforation, absence of the normal light reflex (a cone of light appearing toward the bottom of the drum), or a bulging membrane.
Next, test hearing acuity. Have the patient occlude one ear while you whisper some common two-syllable words toward the unoccluded ear. Stand behind him so he doesn’t read your lips, and ask him to repeat what he heard. Perform the test on the other ear using different words. Then use a tuning fork to perform the Weber and Rinne tests. (See Differentiating conductive from sensorineural hearing loss, page 397.)
Complete your assessment by palpating the patient’s neck and his preauricular, parotid, and postauricular (mastoid) areas for lymphadenopathy. Also, test the function of cranial nerves VII, IX, X, and XI.
Medical causes
Allergy
An allergy associated with tympanic membrane perforation may cause clear or cloudy otorrhea, rhinorrhea, and itchy, watery eyes.
Aural polyps
These polyps may produce foul, purulent, and perhaps blood-streaked discharge. If they occlude the external ear canal, the polyps may cause partial hearing loss.
Basilar skull fracture
With this disorder, otorrhea may be clear and watery and positive for glucose representing cerebrospinal fluid (CSF) leakage, or bloody, representing hemorrhage. Occasionally, inspection reveals blood behind the eardrum. The otorrhea may be accompanied by hearing loss, CSF or bloody rhinorrhea, periorbital ecchymosis (raccoon eyes), and mastoid ecchymosis (Battle’s sign). Cranial nerve palsies, decreased level of consciousness, and headache are other common findings.
Dermatitis of the external ear canal
With contact dermatitis, vesicles produce clear, watery otorrhea with edema and erythema of the external ear canal.
Infectious eczematoid dermatitis causes purulent otorrhea with erythema and crusting of the external ear canal.
With seborrheic dermatitis, otorrhea consists of greasy scales and flakes. The scalp, forehead, and cheeks are also marked by pruritic, scaly lesions.
Epidural abscess
In this disorder, profuse, creamy otorrhea is accompanied by steady, throbbing ear pain; fever; and temporal or temporoparietal headache on the ipsilateral side.
Mastoiditis
This disorder causes thick, purulent, yellow otorrhea that becomes increasingly profuse. Its cardinal features include low-grade fever and dull aching and tenderness in the mastoid area. Postauricular erythema and edema may push the auricle out from the head; pressure within the edematous mastoid antrum may produce swelling and obstruction of the external ear canal, causing conductive hearing loss.
Myringitis (infectious)
With acute infectious myringitis, small, reddened, blood-filled blebs erupt in the external ear canal, the tympanic membrane, and occasionally, the middle ear. Spontaneous rupture of these blebs causes serosanguineous otorrhea. Other features include severe ear pain, tenderness over the mastoid process, and rarely, fever and hearing loss.
Chronic infectious myringitis causes purulent otorrhea, pruritus, and gradual hearing loss.
Otitis externa
Acute otitis externa, commonly known as swimmer’s ear, usually causes purulent, yellow, sticky, foul-smelling otorrhea. Inspection may reveal white-green debris in the external ear canal. Associated findings include edema, erythema, pain, and itching of the auricle and external ear canal; severe tenderness with movement of the mastoid, tragus, mouth, or jaw; tenderness and swelling of surrounding nodes; and partial conductive hearing loss. The patient may also develop a low-grade fever and a headache ipsilateral to the affected ear.
Chronic otitis externa usually causes scanty, intermittent otorrhea that may be serous or purulent and possibly foul-smelling. Its primary symptom, though, is itching. Related findings include edema and slight erythema.
Life-threatening malignant otitis externa produces debris in the ear canal, which may build up against the tympanic membrane, causing severe pain that’s especially acute during manipulation of the tragus or auricle. Most common in diabetics and immunosuppressed patients, this fulminant bacterial infection may also cause pruritus, tinnitus and, possibly, unilateral hearing loss.
Otitis media
With acute otitis media, rupture of the tympanic membrane produces bloody, purulent otorrhea and relieves continuous or intermittent ear pain. Typically, a conductive hearing loss worsens over several hours.
With acute suppurative otitis media, the patient may also exhibit signs and symptoms of upper respiratory infection—sore throat, cough, nasal discharge, and headache. Other features include dizziness, fever, nausea, and vomiting.
Chronic otitis media causes intermittent, purulent, foul-smelling otorrhea commonly associated with perforation of the tympanic membrane. Conductive hearing loss occurs gradually and may be accompanied by pain, nausea, and vertigo.
Perichondritis
In this disorder, multiple fistulas may open on the auricle or external ear canal, causing purulent otorrhea. Typically, the auricle is edematous and erythematous, with thickened skin.
Trauma
Bloody otorrhea may result from trauma, such as a blow to the external ear, a foreign body in the ear, or barotrauma. Usually, the bleeding is minimal or moderate; it may be accompanied by partial hearing loss.
Tuberculosis
Pulmonary tuberculosis may spread through the upper airway to the middle ear, causing chronic ear infection. The tympanic membrane thickens, ruptures, and produces a watery otorrhea and mild hearing loss. Cervical adenopathy may also occur.
Tumor (benign)
A benign tumor of the glomus jugulare (jugular bulb) may cause bloody otorrhea. Initially, the patient may complain of throbbing discomfort and tinnitus that resembles the sound of his heartbeat. Associated signs and symptoms include gradually progressive stuffiness in the affected ear, vertigo, conductive hearing loss and, possibly, a reddened mass behind the tympanic membrane.
Tumor (malignant)
Squamous cell carcinoma of the external ear causes purulent otorrhea with itching; deep, boring ear pain; hearing loss; and, in late stages, facial paralysis.
In squamous cell carcinoma of the middle ear, blood-tinged otorrhea occurs early, typically accompanied by hearing loss on the affected side. Pain and facial paralysis are late features.
Wegener’s granulomatosis
This rare, necrotizing granulomatous vasculitis commonly causes perforation of the tympanic membrane and serosanguineous otorrhea. The patient may report a slowly progressive hearing loss, a cough (possibly hemoptysis), wheezing, shortness of breath, pleuritic chest pain, hemorrhagic skin lesions, epistaxis, and signs of severe sinusitis.
Special considerations
Apply warm, moist compresses, heating pads, or hot water bottles to the patient’s ears to relieve inflammation and pain. Use cotton wicks to gently clean the draining ear or to apply topical drugs. Keep eardrops at room temperature; instillation of cold eardrops may cause vertigo. If the patient has impaired hearing, ensure he understands everything that’s explained to him, using written messages if necessary.
Pediatric pointers
When you examine or clean a child’s ear, remember that the auditory canal lies horizontally and that the pinna must be pulled downward and backward. Restrain a child during an ear procedure by having him sit on a parent’s lap with the ear to be examined facing you. Have him put one arm around the parent’s waist and the other down at his own side, and then ask the parent to hold the child in place. Or, if you are alone with the child, ask him to lie on his abdomen with his arms at his sides and his head turned so the affected ear faces the ceiling. Bend over him, restraining his upper body with your elbows and upper arms.
Perforation of the tympanic membrane secondary to otitis media is the most common cause of otorrhea in infants and young children. Children are also likely to insert foreign bodies into their ears, resulting in infection, pain, and purulent discharge.
Patient counseling
Advise the patient with chronic ear problems to avoid forceful nose blowing when he has an upper respiratory infection so that infected secretions are not channeled into the middle ear. Instruct him to blow his nose with his mouth open. Also, remind him to cleanse his ears with a washcloth only, and not to stick anything in his ear (such as a hairpin or a cotton-tipped applicator) that might cause injury. If the patient is a swimmer, instruct him to wear earplugs and to wash and dry his ears thoroughly after swimming. Have him report recurring ear pain and drainage, especially in the absence of upper respiratory infection, as this may be a sign of cancer.
Tell the patient with a ruptured tympanic membrane that such a rupture usually heals spontaneously. However, warn him to avoid immersing his head in water while it heals; tell him to insert lubricated cotton balls into his ear canal before he showers or shampoos.
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.
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» Next page: Nipple discharge (Professional Guide to Signs & Symptoms (Fifth Edition))
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