|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.
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.
Chronic: Chronic otitis externa, Mastoid cavity, tympanostomy
- Feeding habits
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.
X-rays of the ear, nasopharynx and sinuses.
- Foreign body
- Persistently draining tympanostomy
Chronic otitis externa
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.
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.
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.
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
Usually a history of self inflicted trauma or otherwise can be
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.
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
There may be Haemorrhagic or muco-purulent discharge in the EAM if
the ear drum has perforated.
Chronic suppurative otitis
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
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,
Any granulation tissue of the EAM not responding to an initial
course of treatment should be biopsied.
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.
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.