The Discharging Ear: a Practical Approach

THE DISCHARGING EAR THE DISCHARGING EAR: A PRACTICAL APPROACH

Otorrhoea is a common presenting symptom, the cause of which can usually be established on the basis of the history and clinical examination.

The substances that the ear may discharge include wax, pus, mucus, blood, cerebrospinal fluid (CSF) and saliva. Wax is the normal secretion of the glands of the external ear canal, and patients complaining of wax discharging from the ear should be reassured that it is not abnormal.

The common pathological causes of otorrhoea are the following: • chronic suppurative otitis media (CSOM) with/without cholesteatoma • otitis externa • acute otitis media with perforation of the tympanic membrane • CSF otorrhoea • external or middle ear neoplasms R Y SEEDAT • granulomatous diseases — tuberculosis, atypical mycobacteria, Wegener’s granulomatosis. MB ChB, MMed (ORL), FCORL (SA) Specialist/Lecturer CLINICAL ASSESSMENT Department of Otorhinolaryngology History Universitas Hospital and The evaluation of a patient with otorrhoea starts with his/her history. The patient University of the Free State should be asked about the nature and duration of the discharge, and about the Bloemfontein following otological symptoms: • otorrhoea

Riaz Seedat obtained the MB ChB degree • hearing loss • tinnitus from the University of Natal and spe- • otalgia cialised in ENT surgery at the University of • vertigo the Free State, Bloemfontein. He has been •facial palsy. a consultant in the Department of Otorhinolaryngology at Universitas The colour of the fluid can suggest the cause of the otorrhoea. A purulent dis- Hospital and the University of the Free charge indicates the presence of infection, while a bloody discharge may follow trauma or occur with granulation tissue associated with chronic infection. The State since 2002. His fields of interest presence of a mucoid discharge indicates a perforation of the tympanic mem- include vertigo and paediatric otorhino- brane — there are no mucous glands in the external ear canal; the fluid must laryngology. therefore arise from the middle ear. Clear, watery fluid, especially when associated with a history of trauma or skull base surgery, is likely to be CSF.

Recurrent episodes of purulent otorrhoea suggest CSOM, while purulent otorrhoea of acute onset suggests acute otitis media with perforation of the tympanic membrane, or acute otitis externa. In acute otitis media, the pain characteristi- cally improves when the tympanic membrane ruptures and otorrhoea starts. In otitis externa the pain is persistent. Otitis externa is characterised by a scanty, thin, watery discharge, usually preceded by itching or discomfort in the ear canal.

A foul-smelling discharge is usually associated with cholesteatoma or a neoplasm.

Vertigo and facial palsy associated with otorrhoea are indications for urgent referral. The differential diagnosis of vertigo associated with otorrhoea includes:

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Wax is the normal secre- Examination Special investigations tion of the glands of the A general examination is followed by Besides a pus swab, the only other external ear canal, and an examination of the head and neck special investigation usually necessary patients complaining of region, with particular emphasis on is audiological testing. Radiological the ear. investigations are required only for wax discharging from the complicated cases that should be ear should be reassured After assessing the patient’s hearing referred. that it is not abnormal. with a tuning fork, the pinna and external ear canal should be inspected THERAPEUTIC AGENTS with a headlight. The tragus should be In all cases of a discharging ear, the A purulent discharge indi- palpated, with pain on palpation of patient should avoid allowing water to cates the presence of infec- the tragus or movement of the pinna enter the ear. tion, while a bloody dis- being suggestive of otitis externa. The charge may follow trauma external ear canal and tympanic mem- Medical treatment and/or surgery is or occur with granulation brane should then be examined with indicated in the treatment of a patient an otoscope. tissue associated with with a discharging ear. The various medications that may be used in treat- chronic infection. If the external ear canal is filled with ing a patient with otorrhoea are: discharge, a pus swab should be • systemic antibiotics taken and the ear canal cleaned. Ear No instrument should be • topical antibiotics, e.g. aminoglyco- toilet is of the utmost importance in the sides, quinolones inserted blindly into the ear treatment of otorrhoea with an infec- • topical antiseptics canal as the ear canal, tious aetiology as it improves the qual- • topical steroids tympanic membrane or ity of the examination and efficacy of • topical antifungal agents ossicles may be trauma- ototopical agents. The latter must • analgesics. tised. come into direct contact with affected tissue to be effective. This is done by Topical agents are frequently used in mopping the ear canal using cotton the treatment of most causes of otor- Most cases of CSF otor- buds or, if facilities are available, by rhoea as this modality allows a high rhoea have a traumatic microsuction. The ear canal should concentration of the medication to be always be cleaned under direct vision. aetiology, following a head administered to the affected site while No instrument should be inserted avoiding systemic side-effects. injury or surgery to the blindly into the ear canal as the ear skull base. canal, tympanic membrane or ossicles The common bacterial pathogens in a may be traumatised. Syringing of the discharging ear that can cause an ear is contraindicated in a patient with • complication of CSOM — infection are listed below (often more otorrhoea, as the introduction of water labyrinthine fistula or acute than one organism is cultured): may exacerbate an acute infection labyrinthitis • Pseudomonas aeruginosa and water may enter the middle ear • inner ear erosion by tumour • Staphylococcus aureus through a perforation. • complication of acute otitis media. • Proteus spp. The differential diagnosis of facial • Streptococcus pneumoniae In otitis externa, the skin of the exter- palsy associated with otorrhoea is: • Haemophilus influenza nal ear canal will be inflamed, with • malignant otitis externa • Moraxella catarrhalis. varying degrees of swelling and a • complication of CSOM with small amount of secretions present. cholesteatoma Neomycin is effective against Examination is usually very painful. • malignant neoplasm Staphylococcus aureus and Proteus The presence of pus draining through • Ramsay Hunt syndrome (herpes spp., but has little effect against strep- a perforation or ventilation tube indi- zoster oticus) tococci, Pseudomonas aeruginosa or cates that the middle ear is the site of • skull base fracture. anaerobes, while polymyxin B is effec- infection. In CSOM, a perforation of tive against Pseudomonas, S. aureus the tympanic membrane can be seen. The history should include details of and Proteus spp. Chloramphenicol is The middle ear mucosa may be other symptoms, as well as a general effective against a wide range of inspected through the perforation. A medical history. organisms, but is ineffective against P. marginal perforation, especially when aeruginosa. The fluoroquinolones located posterosuperiorly, is suggestive (ciprofloxacin and ofloxacin) are effec- of cholesteatoma. tive against Streptococcus pneumoniae, Haemophilus influenzae,

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Moraxella catarrhalis, staphylococci This can be started before the patient days until the swelling has subsided. and P. aeruginosa. Ototopical antisep- is referred. The ear canal can then be cleaned tics, such as acetic acid, boric acid, and topical antibiotic and steroid and Burrow’s solution (13% aluminium Topical antibiotics and antiseptics are drops administered. acetate), have bacteriostatic and anti- the mainstay of pharmacological treat- fungal properties because of their ment. An antibiotic-steroid combina- Analgesics should be prescribed for acidic pH. They are effective against tion may be used if granulation tissue the pain. Non-steroidal anti-inflamma- P. aeruginosa, S. aureus, Proteus spp. is present. Systemic antibiotics are tory drugs (NSAIDs) may be required and Candida. indicated only when complications are if the pain is severe. present. The aminoglycosides, polymyxin B, In the case of a fungal otitis externa, chloramphenicol and acetic acid are The presence of systemic symptoms, the ear canal should be cleaned potentially ototoxic, the greatest risk of otalgia, post-auricular tenderness, thoroughly and either 1% acetic acid ototoxicity being associated with use facial palsy or vertigo suggests a com- drops in alcohol prescribed or the ear for more than 7 days and use in a dry plication and warrants urgent referral. canal filled with a topical antifungal middle ear space. The quinolones cream. Clotrimazole is the most effec- have no known ototoxicity. With the OTITIS EXTERNA tive antifungal agent in eradicating availability of these drugs, the use of Otitis externa is a bacterial or fungal Candida and Aspergillus. ototoxic preparations in patients with infection of the skin of the external ear a tympanic membrane perforation canal. P. aeruginosa is the most com- The presence of otitis externa in a dia- should be reserved for cases with cul- mon bacterial pathogen. Fungal otitis betic patient, especially if associated ture of an organism resistant to externa usually arises as a secondary with granulation tissue in the ear canal quinolones. Ototoxicity associated condition after treatment with topical or facial palsy, is strongly suggestive with topical use of antifungal agents antibiotic drops. of malignant (necrotising) otitis exter- has not been reported. na, which requires urgent referral. Otitis externa can be very painful, ACUTE OTITIS MEDIA WITH Administration of topical antiseptic with inflammation and oedema of the PERFORATION OF THE agents can be painful, especially ear canal skin. It can be difficult to TYMPANIC MEMBRANE when applied to inflamed mucosa, distinguish from acute mastoiditis. The because of their low pH. Discomfort lack of post-auricular erythema and Acute otitis media is a common condi- can also occur with use of topical tenderness in otitis externa can be tion, especially in children under the agents that are cold or contain alco- used to differentiate between the two age of 5 years. Otorrhoea may occur hol. conditions. after perforation of the tympanic membrane, with the onset of otorrhoea usu- The topical aminoglycosides, especial- Ear toilet, together with topical antibi- ally being accompanied by relief of ly neomycin, can cause a contact der- otic and steroid drops, is the first-line otalgia. The most common causative matitis. This manifests as erythema treatment of choice for uncomplicated, organisms are S. pneumoniae, H. with swelling and itching of the exter- diffuse, acute otitis externa. There is influenzae and M. catarrhalis. nal ear canal and can easily be con- no evidence that systemic antibiotics, fused with unresponsive otitis externa. alone or in combination with topical Ear toilet and antibiotics directed at antibiotics, improve outcome com- the causative pathogens is the treat- CHRONIC SUPPURATIVE pared with topical antibiotics alone. ment of choice, while fever and otal- OTITIS MEDIA (CSOM) However, systemic antibiotics are indi- gia should be treated symptomatically. CSOM is characterised by chronic cated for the more serious manifesta- Amoxicillin in high doses (80 - 90 infection of the middle ear and mas- tions of this condition, such as periau- mg/kg/day) is the preferred first-line toid and a non-intact tympanic mem- ricular cellulitis and malignant otitis antibiotic for acute otitis media. The brane. CSOM may occur with or with- externa. The use of a topical steroid to use of an antibiotic eardrop in acute out cholesteatoma. reduce the inflammation has a signifi- otitis media with a perforated tympan- cant effect on the pain. ic membrane may result in more rapid The definitive treatment of CSOM is by resolution and prevent secondary surgery (tympanoplasty and/or mas- The ear canal may be swollen to such infection by organisms from the exter- toidectomy) for which the patient an extent that ear toilet and the admin- nal ear canal. should be referred to an otorhinolaryn- istration of eardrops are not possible. gologist. However, initial treatment by In this case, an ear wick coated with a A pus swab may be taken from the ear toilet and ototopical agents is nec- combination of antibiotic, steroid and ear canal, but the result should be essary to prepare the ear for surgery. antifungal cream should be inserted interpreted with caution, as commen- into the ear canal for a period of 1 - 2

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sal organisms from the external ear In most cases the diagnosis can easily IN A NUTSHELL canal may be cultured. be established based on a history of clear, watery otorrhoea after a head In most patients with a discharging POST-VENTILATION TUBE injury or surgery to the skull base. ear, the diagnosis can be made OTORRHOEA Patients may present with a history of based on the history and clinical Infection resulting in otorrhoea is not recurrent meningitis. examination. uncommon in children with ventilation Ear toilet and ototopical agents are In most patients, watery fluid will be tubes (grommets). The bacteria usually the mainstay of treatment of most seen in the external ear canal. This responsible for acute otitis media (S. infective causes of otorrhoea. pneumoniae, H. influenzae and M. can be confirmed as being CSF by catarrhalis), as well as P. aeruginosa testing the fluid for the presence of The definitive treatment of CSOM is and S. aureus, are the most common glucose or beta2-transferrin. The latter surgical, but ear toilet and topical pathogens cultured. The former organ- test is preferred as it has a greater antibiotics or antiseptics are used to isms are more common in children sensitivity and specificity, but it is not prepare the ear for surgery. as widely available. under 3 years of age, while the latter Acute diffuse bacterial otitis externa organisms predominate in children is treated with ear toilet, topical Patients with CSF otorrhoea should be over the age of 3 years. When the antibiotics and steroids, and anal- referred for further management. otorrhoea has become chronic, there gesics. may also be opportunistic infection by Further reading anaerobes and yeasts. Acute otitis media with perforation of the tympanic membrane is treat- Claassen AJ. Trauma and cerebrospinal fluid Initial treatment consists of taking a leakage. Trauma and Emergency Medicine ed with ear toilet, systemic antibi- 1995; 12(6): 214-217. pus swab, ear toilet and administering otics and symptomatically. Topical Hannley MT, Denneny JC, Holzer SS. Use of antibiotic drops may also be help- topical antibiotic drops. Aminoglyco- ototopical antibiotics in treating 3 common ear side eardrops should be avoided as diseases. Otolaryngol Head Neck Surg 2000; ful. 122: 934-940. they are ineffective against pneumo- Holsgrove G, Newby N, Williams R. The Post-ventilation tube otorrhoea coccus and are potentially ototoxic. A chronically discharging ear. Practitioner 1992; should be treated with ear toilet, systemic antibiotic, such as amoxi- 236: 425-429. antibiotic eardrops and systemic Myer CM. Post-tympanostomy tube otorrhea. cillin, should also be given in the pres- Ear Nose Throat J 2001; 80 (Suppl 6): 4-7. antibiotics. ence of an upper respiratory tract Sabella C. Management of otorrhea in infants The presence of vertigo, facial infection. Parents who smoke should and children. Pediatr Infect Dis J 2000; 19: 1007-1008. palsy or systemic symptoms in a be advised to do so outside the house, patient with otorrhoea warrants or preferably to stop smoking. urgent referral. Children should also be removed from day care, but this is usually not possi- CSF otorrhoea is usually post-trau- ble owing to social circumstances. matic. Patients should be referred for further management. The patient should be referred for further management if the otorrhoea per- sists or becomes recurrent. This may include investigation for immunodefi- ciency, intravenous antibiotics and removal of the grommet.

CSF OTORRHOEA

Most cases of CSF otorrhoea have a traumatic aetiology, following a head injury or surgery to the skull base. In rare cases, the cause may be non-traumatic, such as congenital defects, neoplasms or CSOM.

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