How would you manage a discharging ear?
Dr Tira Galm discusses a common presentation
Dr Tira Galm discusses a common presentation
Martin is 23 and has returned from holiday in Florida. While there he spent a lot of time in the swimming pool. His main compliant is of a discharge and severe pain in his left ear, with decrease hearing over the last three days.
What could be the cause?
Otorrhoea is the discharge of material from the external auditory canal. It is both a symptom and a sign, and not a diagnosis. The commonest cause is infection due to acute otitis externa, acute suppurative otitis media and active chronic suppurative otitis media. Other causes include wax, blood and cerebrospinal fluid.
A discharging ear is a common presentation in general practice. It is important the underlying cause is diagnosed as it may be secondary to a serious underlying pathology.
What should the history cover?
• How long has the ear been discharging?
• Is the discharge offensive?
The character of the discharge, may provide vital clue to the aetiology.
The box at the bottom of this article summarises the characteristics of a discharging ear.
If the discharge is suspected to be from the middle ear, consider whether the patient has any symptoms of middle ear complications? Potential implications are also summarised in a box at the end of this article. assage of sound. Anatomically this includes the external canal (acute otitis externa), tympanic
• Hearing loss – commonly conductive deafness. This is caused by disruption in the passage of sound. Anatomically this includes the external canal (acute otitis externa), tympanic membrane and ossicles (chronic suppurative otitis media). membrane and ossicles (chronic suppurative otitis media).
• Otalgia – if the pain is better since the ear has discharged the likely diagnosis is acute otitis media. If the pain is severe and preventing the patient from sleeping (especially in immunocompromised patients) then the diagnosis could be malignant otitis externa.
What other questions should you ask in the history?
• Past medical history. Any immunocompromised patients such as patients with diabetes have the potential to develop malignant otitis externa. It is not a neoplastic condition as the name may imply.
Another name for this condition is necrotising otitis externa. This is a potentially lethal form of otitis externa. Many cases start with a simple otitis externa, which leads to an ulceration and osteitis on the floor of the ear canal. The infection can spread to other areas, including the skull base.
This should be part of the differential diagnosis in patients presenting with severe pain that is out of proportion to clinical signs, and particularly in patients with diabetes.
• Previous ear operations, as the patient may have a mastoid cavity, which has become infected. This is particularly important when you come to examine the patient.
• Ask about risk factors such swimming, dermatitis and hearing aid use, which increase the risk for the ear to discharge.
• Has the patient been on treatment for the discharging ear? This is important as patients on repeated topical antibiotic treatment have the potential to then develop fungal growth, which is exacerbated by topical antibiotic treatment. Patients failing to settle on treatment may have an underlying middle ear pathology, which may not be apparent due to the discharge. These patients should be referred to ENT.
How should you examine the ear?
Start first with examination of the pinna – pericondritis is due to the infection of the cartilage, producing a red/swollen pinna, and can follow severe otitis externa. The infection can also spread to the surrounding tissues, causing facial cellulitis.
Look behind the pinna to examine the mastoid region. If the ear is pulled down and forward with tenderness over the mastoid it is likely to be mastoiditis. A subperiosteal abscess can form, when the infection has broken through the mastoid air cells.
Examination of the external auditory canal may just show that it is full of debris and purulent material, obscuring the tympanic membrane. If inspection of the ear canal shows an ulcer on the canal floor with exposed bone this is diagnostic of malignant otitis externa. Otorrhoea due to fungi appear as a white, yellow or black membrane lining the swollen ear canal.
On examining the external auditory canal a foreign body may be identified, particularly in children. In adults this may be in the form of a cotton wool or the end of an ear bud. Removal can be difficult in children, and therefore should be referred to ENT as occasionally a general anaesthetic is needed.
Assess cranial nerves. For example, it might be seventh nerve palsy, a complication of middle ear infection. Or fifth and sixth nerve palsy (Gradenigo's syndrome) due to petrosititis of the temporal bone, a complication of malignant otitis externa.
Assess neurologically if you suspect meningitis or intracranial complications.
Hearing can be assessed with the Weber and Rinnie test, using the tuning forks.
How should the condition be managed?
• Aural toilet – this may involve mopping the ear in general practice, or referral to ENT for microsuction.
• A swab should be taken before starting treatment.
• Topical treatment should be started, with a combination of steroid and antibiotic.
• Good analgesia is necessary.
• If the patient is diabetic, good glycaemic control is important
• Address risk factors such as swimming (the patient should refrain from swimming until the ear is dry), and against the use of cotton buds in the ear.
• Treat underlying dermatological conditions.
• All patients should be advised to keep the ear dry until the infection has resolved.
• Once the ear is dry, the tympanic membrane and the external canal should be examined to exclude any middle ear pathology, such as cholesteatoma.
When should the patient be referred urgently to otolaryngologists?
• there are middle ear complications
• there is malignant otitis externa
• or pericondritis failing to settle.
Patients should be referred electively if:
• there is a perforated tympanic membrane, and the ear is dry with treatment
• you suspect/or there is a cholesteatoma.
• the discharging ear is failing to settle despite treatment.
Dr Tira Galm is a specialist registrar in ENT at Stafford General Hospital
Characteristics of a discharging ear Characteristics of a discharging ear
Watery - Eczema of ear canal, cerebrospinal fluid
Purulent - Acute otitis externa
Mucoid - Chronic suppurative otitis media with a perforation of ear drum
Mucopurulent or bloody - Trauma, acute otitis media, carcinoma of the ear
Foul smelling - Cholesteatoma
Extracranial: Acute mastoiditis, facial nerve palsy, labyrinthitis
Intracranial:Meningitis, abscess( intracranial, subdural and extradural), lateral sinus thrombosis