1. Ear discharge is a symptom – identify the source of the discharge
The discharge may arise from the ear canal or middle ear. From the skin of the ear canal, it is generally watery, as is seen in otitis externa. Discharge from the middle ear implies a breach of the tympanic membrane, such as a perforation or ventilation tube, and is usually mucoid.
Blood staining is not uncommon with mucoid middle ear discharge. Trauma to the skin, usually caused by the patient trying to clean the ear, may cause fresh bleeding. Infants with sharp nails occasionally cause brisk, fresh bleeding from the ear canal skin.
2. When taking a history, consider relevant causes for the ear discharge
Acute otitis media with perforation and subsequent otorrhoea will usually follow a viral respiratory tract infection with secondary bacterial infection, whereas water contamination tends to point to otitis externa. Acute otitis media occurs in about 80% of children under the age of three. When childhood otitis media is recurrent, such as if the patient is experiencing three or more episodes within six months, or four or more episodes within 12 months, then the patient should be referred to a children’s ENT clinic for specialist advice. Recurrent acute otitis media increases the risk of permanent perforation. Management options include the assessment of immune function, as well as seasonal prophylactic antibiotic treatment, ventilation tubes, or both.
Otorrhoea due to otitis externa may be associated with systemic skin disorders like eczema or psoriasis, but is more commonly related to water contamination of the ear. The occupational use of ear defenders or wearing hearing aids increases the humidity in the ear canal and can cause recurrent otitis externa, so patients should avoid using these during an infective episode.
Habitual cleaning of the ears, be it with cotton buds, hairgrips, or car keys, irritates and traumatises the skin, increasing the risk of infection.
Pain, irritation and blockage of the ear are common with otitis externa, but less so with mucoid discharge from the middle ear. The latter can lead to a secondary otitis externa from maceration of the external canal skin. Tinnitus can result from the temporary conductive hearing loss, while vertigo is uncommon in uncomplicated otitis externa or otitis media.
3. Examine the ear carefully
Examine the external ear for signs of irritation and infection in the skin of the concha. With otitis externa, small pre and post-auricular lymph nodes may be palpable. Look for scars in front and behind the ear, indicating previous surgical treatment of middle ear disease.
Examine the mastoid bone for inflammation and tenderness, with associated forward protrusion of the ear. Mastoiditis is more common in young children, following an acute otitis media. In this younger group, early systemic antibiotic treatment is indicated.
It can sometimes be very difficult to differentiate severe otitis externa from early acute mastoiditis on examination alone. If in doubt, refer urgently.
Use bright halogen otoscopy to examine the ear canal and visualise the tympanic membrane if possible. Carefully examine the attic and posterior marginal areas of the tympanic membrane to confirm or exclude keratin build-up in these areas, which could represent a deeper-seated cholesteatoma with recurrent infection causing discharge.
A boil in the ear canal can be exquisitely painful with little discharge, but causes intense inflammation in the ear canal. In this instance, systemic and topical antibiotics are indicated.
Examine the central part of the tympanic membrane to confirm or exclude a perforation.
4. Do not syringe the ear
Syringing an ear canal full of discharge will usually cause pain, and can aggravate otitis externa. The usual – and most common – causative organism, Pseudomonas aeruginosa, grows best in a wet environment. Syringing might damage the tympanic membrane, and if a perforation is present, force skin bacteria into the middle ear, compounding the infection.
5. Do not try and remove a foreign body
Foreign bodies in the ear canal, particularly organic foreign bodies, can become infected. In a non-competent adult or cooperative older child, referring a patient for a removal using microscopy and micro-instruments is the safest option. For younger children or adults with difficulties cooperating for ear instrumentation, microscopic examination under a short general anaesthetic is advisable.
6. Consider which type of treatment to use
For uncomplicated otitis externa, use combined aminoglycoside and steroid antibiotic eardrops. If the external ear skin is infected, consider adding an oral antibiotic to cover Staphylococcus aureus.
For otitis media with perforation and discharge, combine a broad-spectrum oral antibiotic with a quinolone eye drop and steroid eardrop to avoid the theoretical risk of ototoxicity. Without combination, the primary acute otitis media discharge will provide a medium for ear canal commensals – such as Proteus and Pseudomonas – to grow, leading to a persistence of otorrhoea and repeated courses of oral antibiotics without any benefit.
Prolonged use of topical antibiotic eardrops should be avoided, as this is likely to result in a yeast or fungal infection. Treat such an infection with clotrimazole solution as eardrops.
If the ear canal in swollen and almost closed, the patient should be referred urgently for microsuction, wick insertion, and antibiotic treatment.
7. Review within seven to 10 days
Reassess following the initial treatment and re-examine the ear.
If any discharge persists, send a swab for bacteriology to exclude antibiotic resistance, using a fine wire bacteriology swab to ensure the most representative sample.
If the discharge persists, refer for specialist assessment, microscopic suction cleaning and examination of the ear. In acute otitis externa, it is often not possible to assess the ear canal or tympanic membrane because of canal oedema. Other conditions can masquerade as simple otitis externa, so reviewing when the acute phase has subsided is advisable.
8. In persistent or recurrent otitis externa, consider dermatological advice
In those with recurrent otitis externa, while the condition is localised, it can represent part of a wider dermatological picture.
Seborrhoeic dermatitis, psoriasis, lichen planus and other skin conditions can present in the ear canal and may not respond to the usual topical treatments.
9. Consider urgent referral if red flag signs or symptoms are present or develop
Necrotising otitis externa in those with either type 1 or type 2 diabetes carries a significant mortality. Timely specialist management is essential, and these patients should be referred urgently.
Urgently refer those with otitis media also presenting signs of mastoid inflammation.
Chronic remitting and relapsing mucoid discharge might represent an underlying perforation or cholesteatoma, and requires specialist assessment.
Clear watery discharge from the ear following a head injury is likely to be CSF otorrhoea, and should be investigated as a matter of urgency.
Ear discharge in association with abnormal neurology, vertigo, diplopia, facial weakness, headache or pain disproportionate to the clinical findings is an indicator of intracranial spread of infection, and should result in instant referral.
10. Advise on prevention of future infections
Recurrent otitis externa and recurrent infected discharge through a perforation that is not amendable to surgical repair can be mitigated by keeping the ear dry. Soft mouldable earplugs – or customised ear moulds for keen swimmers – are very helpful.
Advise on avoiding cleaning the ears or trying to dry them with a towel, which helps to reduce irritation of the skin.
For itchy ears in the absence of infection, OTC acetic acid spray is helpful.
Mr Peter Robb is a consultant ENT surgeon, with an interest in paediatric ENT, at Epsom & St Helier University Hospitals, The Clock House, Epsom and Ramsay Ashtead Hospital, Surrey.
Robb PJ, Watson A. ENT in Primary Care. RILA publications, London. 2007. ISBN 9781899839070.
Pankhania M, Judd O, Ward A. Otorrhoea. BMJ 2011; 342:d2299.