Otorrhea

Otorrhea, or ear discharge, usually results from an inflammatory process in the ear canal, middle ear, or mastoid. A thorough cleaning of the ear canal (with suction if possible) is essential to determine the source of the otorrhea. Ear lavage should be avoided in the presence of otorrhea, because of possible injury to the inner ear if the tympanic membrane is perforated, commonly from otitis media. CSF otorrhea must always be considered in patients with recent face or head trauma or surgery.

Differential Diagnosis

• Otitis externa (swimmer's ear)
  –Most common source of otorrhea
  –Usually associated with water contamination or cotton swab abuse
  –Pain with movement of pinna
  –Usually secondary to Pseudomonas or Staphylococcus infection

• Malignant otitis externa
  –Also known as necrotizing external otitis and skull base osteomyelitis
  –Suspect in patients with diabetes or immunosuppression who present with persistent otorrhea, ear pain, and granulation tissue in the ear canal
  –Usually secondary to Pseudomonas
• Foreign body
  –Frequently a retained cotton swab
  –Often occurs in toddlers
• Otitis media (acute or chronic) with perforated tympanic membrane
• Cholesteatoma
  –A skin-lined cyst of the middle ear or mastoid that occurs secondary to chronic otitis media
  –In most cases there is fullness, bulging, or a white mass of the tympanic membrane (may easily be confused with ear wax)
• Mastoiditis
  –Tenderness or bogginess over mastoid

• Cerebrospinal fluid otorrhea
  –Clear, colorless discharge through a tympanic membrane perforation or tympanostomy tube
  –Patients usually have a history of trauma or surgery, but CSF otorrhea may occasionally be spontaneous

Workup and Diagnosis

• History should focus on onset, duration, appearance of discharge, associated symptoms, activity history (e.g., swimming), and past history (e.g., frequent otitis, tympanostomy tubes, diabetes)

• A thorough cleaning of the ear canal under direct visualization (with magnification is ideal) with a curette or suction is necessary to determine the source of discharge
  –The presence or absence of tympanic membrane pathology must be determined
  –The absence of tympanic membrane pathology usually signifies that the source of otorrhea is limited to the external ear canal
  –Unless the ear canal is cleaned with suction, many pathologies will not be identified
  –Ear lavage should be avoided in the presence of otorrhea
• Ear cultures from the canal may be helpful in persistent cases; however, contamination by normal ear canal flora usually decreases their value
• If CSF otorrhea is suspected, an assay for β₂ transferrin will identify CSF from other fluids
• CT of the temporal bones is helpful in evaluation of patients with suspected cholesteatoma, mastoiditis, and CSF otorrhea
• Gallium and technetium scans may be helpful in patients with malignant external otitis

Treatment

• Otitis externa is treated with antibiotic drops; alternatively, acidification of the ear canal with acetic acid is also effective; patients should follow water precautions and abstain from the use of cotton swabs
• Otomycosis of the ear canal is also treated with topical antifungal preparations as well as acidification
• Otitis media with tympanic membrane perforation should be treated with systemic antibiotics; precautions should be taken with topical antibiotics because many are known to be ototoxic (only ofloxacin is approved for usage in the middle ear)
• Foreign bodies in the ear can be removed with alligator forceps under direct visualization, or the patient can be referred to an otolaryngologist emergently
• Patients with cholesteatoma, mastoiditis, and cerebrospinal fluid leak should be emergently referred to an otolaryngologist

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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