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Discharging ear


part 1
part 2
part 3
part 4
part 5

part 6

Few problems are as frustrating to the otolaryngologist as the persistently draining ear.

The management of the problem hinges upon the ability of the physician to determine the site of origin and the underlying cause of this drainage.

Types of ear discharge

  • Waxy: Wax , Keratosis obturans.
  • Haemorhagic: Trauma, acute otitis media, chronic otitis media, herpes zoster, bullous myringitis, tumor.
  • Mucoid: ASOM, CSOM.
  • Purulent: External otitis, foreign body, Myringitis, ASOM, CSOM, tumors.
  • Sero-sanguinous: External otitis, foreign body, HVZ, CSOM. Watery: CSF, atopic dermatitis.

Approach

History:
    • Onset
    • Duration:
    • Acute:
    • Chronic: Chronic otitis externa, Mastoid cavity, tympanostomy tubes
    • Progression
    • Past treatments
    • Associated phenomenon:
    1. Deafness
    2. Tinnitus
    3. Vertigo
    4. Feeding habits
    5. Snoring

Examination:

    • Aural toilet by either cotton applicator or suction. Do not use syringing to clean a discharging ear.
    • Determine site by systematically examining the pinna, external auditory meatus, tympanic membrane and the middle ear.
    • Assess hearing by voice tests, tuning fork tests and after aural toilet by PTA.
    • In cases of CSOM or recurrent ASOM, assess eustachian tube function after controlling the acute episode.
    • Examine the rest of the ENT, paying special attention to tonsils and adenoids, and nasal obstructive lesions.

Investigations:

    • CBC
    • C/S
    • X-rays of the ear, nasopharynx and sinuses.

Age related etiologies

Children:

    • ASOM
    • Otomycosis
    • Foreign body
    • Persistently draining tympanostomy tubes
    • trauma

Adults:

    • Otomycosis
    • CSOM
    • Chronic otitis externa (Swimmer’s ear)
    • Mastoid cavity

Middle aged:

    • External otitis (Diabetics)
    • Tumors

Elderly:

    • External otitis
    • Tumors
    • ASOM
    • Trauma

Diagnostic features

Otomycosis
    • Patients of all ages can develop fungal infection with Aspergillus niger and albus.
    • Pain, itching, blocked ear and a discharge like a wet blotting paper lead to medical consultation.
    • Either a history of getting water in the ear (Bath, swimming) or high atmospheric humidity during the monsoon months can be elicited.
    • On examination there is erythema of the EAM, with thick whitish yellow discharge with black specks.

Furuncle

    • All age groups are affected. Diabetics are more prone.
    • Trauma or scratching the ear usually precedes.
    • Severe edema and redness at the entrance of the EAM, commonly on the floor or the anterior wall in the early stage. A yellow point may be visible later. Rest of the EAM is patent and normal.
    • Severe tragal tenderness.
    • Some Haemorhagic or purulent discharge may be present if the furuncle has ruptured.

Herpes zoster

    • May occur at any age, but mainly it does so between 40-60 years.
    • The patient is generally unwell with erythema and vesicles on the auricle, EAM and sometimes on the tympanic membrane. Haemorhagic discharge may be present.
    • Severe neuralgia.
    • In severe cases VII, VIII, IX nerve may become involved with facial palsy, vertigo, and retrocochlear deafness.
    • Has to be differentiated from myringitis bullosa by viral serology.

Trauma

    • Usually a history of self inflicted trauma or otherwise can be obtained.
    • In case of injury to the EAM, a partial degloving of the skin of the EAM with fresh or clotted blood is identifiable. In late presentations there is severe pain, Cellulitis with purulent discharge in the EAM.
    • In case of injury to the tympanic membrane, there is blood in the EAM, with a ragged laceration of the ear drum. The edges of the tear are turned towards the middle ear.

Foreign body

    • The patient a child or an adult presents with discharge which may be foul smelling in case of a vegetable foreign body. There may be a past history of the child sticking things up his ears or nose. Suction of the discharge reveals the problem. The adult may date back his problem to an episode of ear cleaning with a cotton bud.

Acute suppurative otitis media

    • The patient usually a child or a young adult presents with a short history of otalgia, and fever preceded by an upper respiratory tract infection. The tympanic membrane appears dull, heamorrhagic, and in severe cases bulging and threatening rupture.
    • There may be Haemorrhagic or muco-purulent discharge in the EAM if the ear drum has perforated.

Chronic suppurative otitis media

    • Largest category of patients.
    • Presence of profuse mucoid to mucopurulent discharge wit ha central perforation leads to a diagnosis of tubo - tympanic CSOM.
    • Scanty foul smelling purulent discharge sometimes tinged with blood, in the presence of a marginal perforation and irregular keratinous debris is usually due to Attico-antral CSOM.
    • The presence of a scar either post aural or endaural, and the presence or absence of the posterior wall of the EAM must be noted. Evaluation of the previously operated ear must be concerned with the presence of persistent or recurrent cholesteatoma, mucosalisation of the mastoid cavity, or the presence of granulation tissue.

Tumor

    • Benign neoplasms of the EAM are frequently epithelialised but inspissation of the epithelial debris may occur medial to the obstructing mass.
    • Malignant neoplasm may present with purulent discharge, bleeding, and otalgia.
    • Any granulation tissue of the EAM not responding to an initial course of treatment should be biopsied.

Keratosis Obturans

    • Characterized by abnormal accumulation of epithelial debris within an expanded bony ear canal. A large plug of whitish debris is seen covered with a thin layer of wax. The problem comes to light when during a routine cleaning of wax, the epithelial cast of EAM is seen.
    • Presents with pain, hearing loss, and suppuration.

Myringitis

    • Diagnostic features include the presence of granulation tissue on the surface of the tympanic membrane and adjacent EAM. The topographic features of the tympanic membrane may be obscured behind soft velvety granulations.

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