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Otorrhea is drainage exiting the ear. It may be serous, serosanguineous, or purulent. Drainage may originate from the ear canal, the middle ear, or the cranial vault. Associated symptoms may include otalgia, fever, pruritus, vertigo, tinnitus, and hearing loss.

Etiology

Causes of acute (< 6 wk) otorrhea include acute otitis media with perforation of the tympanic membrane, otitis externa, drainage through a patent tympanostomy tube, recent trauma (causing CSF leak), and surgery.

Causes of chronic otorrhea (which may also present acutely) include chronic purulent otitis media, cholesteatoma, foreign body, Wegener's granulomatosis, necrotizing otitis externa (frequently associated with immunodeficiency and diabetes), mastoiditis, and osteomyelitis (bacterial, fungal, or TB).

Evaluation and Treatment

History: Acute otalgia with relief after appearance of otorrhea suggests acute otitis media with perforation. A history of swimming or seborrheic dermatitis suggests otitis externa. Recent head trauma or surgery suggests CSF leakage. A history of tympanic membrane perforation or chronic eustachian tube dysfunction suggests cholesteatoma. A history of untreated or poorly treated acute otitis media suggests mastoiditis.

Physical examination: Otoscopic examination can usually diagnose perforated tympanic membrane, external otitis media, foreign body, or other uncomplicated sources of otorrhea. Crystal clear fluid is usually CSF, although with trauma fluid may be bloody. Flaky debris littering the ear canal suggests cholesteatoma. Periauricular swelling and intense tenderness, granulation tissue within the canal, and facial nerve paralysis suggest necrotizing otitis externa. Redness and tenderness over the mastoid suggest mastoiditis.

Testing: If CSF leakage is in question, discharge can be tested for glucose or β₂-transferrin. Patients without an obvious etiology on examination require audiogram, CT scan of the temporal bone or gadolinium MRI scan, or pathologic examination of granulation tissue in the auditory canal. Most physicians will not treat a suspected CSF leak with antibiotics without a definitive diagnosis so as not to mask the onset of meningitis.

Treatment: Treatment depends on the final diagnosis. Antibiotics are administered, as appropriate, for infectious causes.

Last full review/revision November 2005

Content last modified November 2005