AURAL DISCHARGE (OTORRHEA)

The differential diagnosis of a nonbloody discharge of the ear can best be done by using anatomy. Visualize the components of the ear apparatus. A discharge may arise from the external canal, the middle ear, the mastoids and petrous bone, the inner ear, or the cerebrospinal fluid. As elsewhere in the body, nonbloody discharge signifies inflammation and infectious or allergic conditions, but foreign bodies and malignancies can trigger an infection by causing an obstruction or lowering resistance. The external canal may be involved by bacterial infection as in furunculosis, diffuse otitis externa, and Eaton agent pneumonia and by viral infection in herpes zoster (Ramsay Hunt syndrome). Fungi may infest the external canal, particularly when wax or a foreign body accumulates. Atopic, contact, or seborrheic dermatitis may also involve the external canal. In the middle ear, bacterial infections may produce an acute or chronic purulent otitis media with or without rupture of the drum, but a serous otitis media from allergy, viral infections, or obstruction of the eustachian tube does not usually cause otorrhea. In addition to perforation, otitis media may lead to mastoiditis, petrositis, and ultimately to a chronic granuloma called a cholesteatoma. All of these are usually associated with a chronic continuous or intermittent nonbloody discharge. Conditions arising in the inner ear (e.g., labyrinthitis) are rarely associated with otorrhea, but a basilar skull fracture may lead to cerebrospinal otorrhea. This is usually bloody at onset, but if it goes unrecognized it may become clear or, when infected, purulent.

Approach to the Diagnosis

The approach to the diagnosis of an aural discharge is similar to the approach for discharges from any body orifice. After careful examination for a foreign body or obstruction, the discharge is cultured and appropriate therapy begun. A gram stain of the material often aids in the determination of the most appropriate antibiotic. If the discharge is chronic, x-rays of the mastoids and petrous bones may be necessary, as well as tomography. Obviously, referral to an otolaryngologist is wise at this point.

Other Useful Tests

1. CBC (infection)
2. Sedimentation rate (inflammation)
3. Acid-fast bacillus (AFB) and fungal smear and culture
4. Tuberculin test
5. VDRL test (syphilis)
6. CT scan of the brain, mastoids, petrous bones (neoplasm, mastoiditis, cholesteatoma)
7. Biopsy
8. Tympanogram (otitis media)

Pictures

Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins MD, FACP
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins MD, FACP Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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