Ear Discharge (Otorrhea)

Introduction

Ear discharge (otorrhea) in adults is not as commonly seen as in the pediatric population, but its complications can be devastating. Most commonly, otorrhea in adults is secondary to trauma, but other etiologies such as infection should also be ruled out.

Differential diagnosis

• Purulent otorrhea: acute and chronic suppurative otitis media, malignant otitis, Swimmer’s ear.
• Non-purulent otorrhea: Swimmer’s ear, foreign body, CNS fluid leakage, invasive otitis externa.
• Bloody otorrhea: trauma to external canal or middle ear, barotrauma, foreign body.

History and physical exam

The history of the patient with otorrhea should include the following:

• Duration of symptoms
• Presence of fever
• History of trauma to upper body especially above the shoulders
• History of swimming
• Does the patient clean his/her ears with cotton-tipped swabs
• Pruritus in ear
• Upper respiratory symptoms compatible with viral infection
• History of recent air travel
• History of recent diving
• Hearing loss. 
• If the patient looks toxic document the presence or absence of mental status changes as well as other systemic signs.

The physical exam should include:

• Inspection of the external ear and canal
• Palpation of the mastoid bone
• Palpation of the neck
• Inspection of the tympanic membrane
• Insufflation of air in the canal to document adequate movement of the tympanic membrane. 
• A neurological exam is appropriate in toxic patients and in those patients complaining of headache or with a history of trauma.

Diagnosis and treatment

Otitis externa

Also known as swimmer’s ear, this condition occurs most commonly in the summer and results from a decrease in the acidity of the external canal. The ear will be itchy and painful. The canal will red and swollen. Depending upon the duration of the infection, it will also have either a clear or purulent discharge. The most common pathogens are streptococci, Pseudomonas aeruginosa and Staphylococcus aureus.

Treatment is very simple and consists of topical antibiotics to the canal such as polymixin-neomycin in the following doses: four drops four times a day for at least five days. May also add alcohol-acetic acid mixtures to above regimen to clean the canal.

Invasive otitis externa.

Also known as invasive otitis externa, this condition is a very serious entity that usually affects diabetic, debilitated and/or immunocompromised patients. It is caused by P. aeruginosa when it invades the soft tissues adjacent to the external ear canal quickly spreading to mastoid and temporal bone and eventually across the base of the skull.

The patient will present with ear pain (otalgia) and discharge for several months. Physical exam will reveal a purulent discharge and edema in canal with granulation tissue evident in the posterior wall. Partial paralysis of cranial nerves VII, IX, X and XI may also be present. Fever, meningitis and brain abscess are rare.

Treatment requires surgical intervention and long term antibiotics. In the setting of an isolated duty station or a small ship the patient will have to be MEDEVAC'd as soon as possible for definitive diagnosis and treatment. Do not bother in obtaining ear canal cultures as these are unreliable and deep tissue cultures are needed for proper antibiotic treatment. Ct and MRI are a must as these studies will guide the surgeon in deciding which surgical approach will be the best. If immediate transfer the patient is not feasible, empiric antibiotic therapy should cover P. aeruginosa, S. epidermidis, Aspergillus, Fusobacterium and Actinomyces: ticarcillin, piperacillin or ceftazidime with an aminoglycoside are the drugs of choice. Remember, however, that this entity needs surgical intervention and long term antibiotics (at least for six weeks), therefore transfer of the patient is a priority.

Suppurative otitis media

This is an infection of the middle ear with drainage of pus through a perforated tympanic membrane.

The patient will initially complain of severe otalgia that suddenly improves after noticing some ear discharge.

Offending organisms are the following: S. aureus, P. aeruginosa and enteric gram negative bacilli such as Klebsiella, E. coli, and Proteus. Fifty percent of patients will also have anaerobes organisms such as: Prevotella, Fusobacterium, Porphyromonas and Bacteroides.

Treatment consists of oral antibiotics specifically directed to the offending organism after identification has been achieved with cultures. Empiric treatment can be started using Amoxicillin 500 mg po q 12h or Augmentin 500 mg po q12h. It is also important to perform a CT scan to rule out cholesteatoma and mastoid sequestrum which require surgical drainage. 

Tympanic membrane perforation

A perforated tympanic membrane may present with or without ear discharge. Those presenting with otorrhea are most likely secondary infected with bacteria, and cultures should be taken immediately. Antibiotic treatment is directed to the pathogen identified. It is important to assess hearing acuity to rule out damage to the ossicles.

Vertigo or a sensorineural hearing loss suggests that a portion of an ossicle or a missile has been driven into the inner ear or that there is a fistula between the perilymphatic space of the vestibule and the middle ear. These conditions require surgical intervention, therefore the patient should be transferred to a facility with surgical subspecialty capabilities, however this does not have to be done emergently. The great majority of tympanic membrane perforations heal spontaneously within six weeks. During this period the patient should be advised not to put any instrument in the ear such as cotton-tipped swabs and to avoid the introduction of water and other fluids. If desired, coverage with oral penicillin for seven days can be recommended.

Bleeding from the ear

Bleeding from the ear following head trauma is a very ominous sign. When the bleeding is from the middle ear it is a pathognomonic sign of temporal bone skull fracture. The initial approach to a patient presenting with this symptom includes: initial ABC’s, stabilization of the cervical spine and immediate transfer to a medical facility with surgical/neurosurgical capabilities for definite treatment. If possible a brain CT scan should be performed but should not delay emergent management or transfer. Avoid cleaning the ear canal to avoid introduction of bacteria that could cause meningitis and initiate prophylactic treatment with broad spectrum antibiotics.

This section provided by LCDR Antonio E. Rodriguez, MC, USNR, Naval Medical Center Portsmouth

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