EAR DISCHARGE

(OTORRHEA)
Definition
• OTO = EAR
• -RRHEA = FLOW
• Otorrhea = is drainage exiting the ear. It may be serous,
serosanguineous, or purulent. Associated symptoms may
include ear pain, fever, pruritus, vertigo, tinnitus, and hearing loss
• It may originate from ear canal, middle ear, or cranial vault
Otitis externa
• Acute diffuse otitis externa (swimmer’s ear)
• Acute localized otitis externa (furuncle)
• Chronic otitis externa
• Eczematous otitis externa
• Fungal otitis externa (fungal otitis externa)
• Malignant otitis externa (osteomyelitis of temporal bone)
Otitis media
• ASOM (Acute suppurative otitis media)
• CSOM (Chronic suppurative otitis media)
• OME (otitis media with effusion)
CSF otorrhea
• Congenital
• Defects in otic capsule
• Abnormal patency
• Acquired
• Post operative
• Trauma
• Infection
• neoplasm
Otitis externa
 Otitis Externa
• Acute Diffuse Otitis Externa (swimmer’s ear)
• Acute Localized Otitis Externa (Furuncle)
• Eczematous Otitis Externa
• Fungal Otitis Externa
• Malignant Otitis Externa
 Acute Diffuse Otitis Externa
Diffuse inflammation of meatal skin which may spread to involve pinna and
epidermal layer of tympanicmembrane
• Common in hotand humid climate and in swimmers
– Excessive sweating changes pH of meatal skin from acidto alkaline which
favours growth ofpathogens
• 2 common risk factors:
– Trauma to meatal skin (scratching ear canal with hair pins/matchsticks,
vigorous cleaning of ear canal after a swim when skin is alreadymacerated)
– Invasion by pathogens
– Secondary infection of middle ear, allergic sensitizationto opical ear
drops
• Common organisms:
- Bacterial ; Ps. aeruginosa, staph.aureus, Ps. pyocyaneus,, E. coli,mixed.
- Fungal ; Candida albicans, Aspergillus niger
• Clinical features:
– Acute :
• hot burning sensation in ear, followed by pain whichaggravated by movement of jaw
• starts oozing thin serous discharge which later become thickand purulent
• meatal lining inflammed and swollen, collection ofdebris and
• discharge with swelling cause conductive hearingloss
• severe case causes LN enlarged and tender with cellulitis of
• surrounding tissue
– Chronic:
• Irritation and strong desire to itch(acute exacerbation and reinfection)
• Discharge is scanty and dry up to formcrusts
• Thick and swollen meatal skin show scaling and fissuring
• Rarely, skin hypertrophic leading to meatalstenosis
• Treatment:
– Acute :
• Ear toilet (attention to anterior inferior meatal recess which forms a blind pocket)
• Medicated wicks with gauze (local steroid relieve oedema, erythema, itching)
(aluminium acetate 8%/ silver nitrate3% are mild astringents to form protective
coagulum to dry up oozing meatus)
• Topical Antibiotics (systemic antibiotic if cellulitis and acute tenderlymphadenitis)
• Analgesics for painrelief
– Chronic :
• Reduction of meatal swelling so that ear toilet can bedone
• Alleviation of itching so that scratching isstopped (e.g corticosteroid alone – diprosalic
acid)
• Gauze soaked in 10% ichthammol glycerine is inserted into canals to reduce swelling,
followed by eartoilet
• Surgically excised for chronic stenotic OE (bony meatusis widened with a drilland lined by
split- skin graft)
 Acute Localized Otitis Externa (Furuncle)
• Staphylococcus infection of the hair follicle which are only confined to
cartilaginous part of meatus.
• Severepain & tenderness in movementof pinna, jaw movements,
pressure on tragus &concha (can be out of proportion to size of furuncle)
• Furuncle in posterior meatal wall causes oedema overmastoid with obliteration
of retroauricular groove
• Periauricular LNmay enlarge andtender
• Treatment:
– systemic antibiotics, analgesics, local heat for earlycases
– Ear pack of 10% Ichthammol glycerine (IG) provide splintage & reduce pain
(hygroscopic action of glycerine reduce oedema, ichthammol asantiseptic)
– Incision & drainage for abscess formationcases
 Eczematous Otitis Externa
• Result of hypersensitivity to infectiveorganisms/ topical ear drops
(chloromycetin/neomycin)
• Clinical features:
– Intense irritation
– vesicle formation
– oozing and crusting in canal.
• Treatment:
– withdrawal of topicalantibiotic
– application of steroidcream
 Fungal Otitis Externa
• Fungal infection due to Aspergillus niger (black-headed filamentous growth), A.
fumigatus(pale blue/green)or Candida albicans (white/creamydeposits)
• Seenin hot humid climate of tropical and subtropical
• countries
• Secondary fungal growth in patient using topicalantibiotics
• Clinicalfeatures:
– intense itching
– Earpain
– watery discharge with mustyodour
– ear blockage with white/brown/black fungalmass
– meatal skin sodden, red, oedema
• Treatment:
– Ear toilet (syringing, suction, mopping)
– Antifungal for week even after cure to avoid recurrence (Nystatin
against Candida, clotrimazole, povidone iodine)
– 2% salicyclic acid in alcohol as keratolytic agent which removes
superficial layers of epidermis withfungal mycelia growing into them
– Keep ear dry
– Antibiotic/steroid to reduce inflammation and oedema thus
permitting better penetration of antifungal agents
 Malignant (necrotizing) Otitis Externa
• Inflammation caused by pseudomonas infection in elderly diabetics, or
those in immunosuppressive drugs
• Early resemble diffuse OE, otalgia and otorrhea refractory to medical tx. t is
osteromyelitis of temporal bone.
• Diagnosis:
– Severe otalgia in elderly diabetic patient withgranulation tissue in ear canal at its
cartilaginous-bony junction
– Gallium-67 taken up by monocytes and reticuloendothelial cells indicate soft
tissue infection (useful for diagnosis and follow up, repeat every 3weeks)
– Technetium 99 bone scan reveals bone infection but it remains positive for ayear
• Facial paralysis is common, infection may spread to skull base and jugular
foramen cause multiple CNpalsies
• Treatment:
– Diabetic control
– Eartoilet
– Debridement of necrotic tissue/bone
– Antibiotics for 6-8weeks
• Gentamicin( ototoxic, nephrotoxic ) + ticarcillin (givenIV)
• 3rd gen cephalosporins (ceftriaxone 1-2g/day IV, ceftazidime 1-2g/day IV
with aminoglycoside)
• Quinolones (ciprofloxacin 750mg OD orally), can combined with
rifampicin
 Primary Cholesteatoma of External Auditory Canal

• Squamous epithelium of canal invades its bone which is

conducive for epithelium to invade it (post-traumatic/post-
surgery)
• Clinical features:
– Purulent otorrhoea and pain, TM normal
• Treatment :
– removal of necrotic bone and cholesteatomaand lining the defect with
fascia
Otitis media
Otitis media
• ASOM
• CSOM
• OME (otitis media with effusion)
# So basically children have
shorter, wider and
more horizontal
Eustachian tube.
ASOM (acute suppurative otitis media)
• Cause by pyrogenic organism
• Typically follows viral infection of URTI
• Routes of infection
• Eustachian tube
• External ear after perforation of TM
• Blood borne (rare)
• Common in young infant
• Because shorter, wider, less angle eustachian tube
Predisposing factor
1. Eustachian Tube dysfunction or
obstruction.
 swelling of tubal mucosa
 obstruction of Eustachian tube ostium
 Abnormal Eustachian tube
1. Disruption of action of
- cilia of Eustachian tube (eg.
Kartagener’s syndromes
- Mucus secreting cells
2. Immunosuppression/deficiency
eg. Chemotherapy, steroids, DM,
cystic fibrosis
Common microorganism
• Common
• Streptococcus pneumoniae (30%),
• Haemophilus influenzae (20%)
• Moraxella catarrhalis (12%).
• Others
• Streptococcus pyogenes
• Staphylococcus aureus
• Pseudomonas aeruginosa

• Many strains of H. influenzae and M. catarrhalis are β-lactamase

producing.
Pathology and Clinical Features by Stages
Stages:
1. Tubal Occlusion
2. Pre-suppuration
3. Suppuration
4. Resolution
5. Complication
Stage 1: Tubal occlusion
Oedema & hyperaemia of nasopharyngeal
end of eustachian tube blocks the tube.

Air absorbed in middle ear & negative

intratympanic pressure (Irritant to middle
ear mucosa).

Retraction of tympanic membrane with

some degree of effusion in the middle ear
(fluid may not be clinically appreciable).
Stage 1: Tubal occlusion

Symptoms: Deafness and earache

(not marked). No fever.
Signs:
-Otoscope: TM retracted, handle
of malleus assume more
horizontal position, light reflex
loss, prominent lateral process of
malleus.
- Tuning fork: CHL
Stage 2: Pre-suppuration

If prolonged tubal occlusion

Invasion of tympanic cavity by

pyogenic organisms causing
hyperaemia of its lining.

Inflammatory exudates appear in

middle ear, tympanic membrane
becomes congested.
Stage 2: Pre-suppuration

Symptoms:
- Marked throbbing earache
- Adults: Deafness and tinnitus
- Children: High fever and restlessness
Signs:
- Otoscope: Congestion of pars tensa,
leash of Blood Vessel appear on
handle of malleus & periphery of TM
(Cartwheel appearance), later whole
TM becomes uniformly red.
- Tuning fork: CHL
Stage 3: Suppuration

Formation of PUS in
middle ear and to some
extent in mastoid air cells.

TM starts bulging to
the point of rupture.
Stage 3: Suppuration
Symptoms: Yellow spots
- Excruciating earache + increasing
deafness
- Children: High grade fever +/-
vomitting and convulsion
Signs:
- Otoscope: TM appear red & bulging,
loss of landmark, handle of malleus
engulfed by swollen & protruding TM, Bulging TM
yellow spots on TM.
- Tender mastoid antrum
- X-ray of mastoid show clouding of air
cells (exudate)
 Stage 4: Resolution

Tympanic membrane
ruptures

Release of pus – ear

discharge.

Inflammatory process and

symptoms start to resolve.
- If mild infection or treatment started early, resolution may start even without
rupture of TM
Stage 4: Resolution

Symptoms: Earache relieved, fever

comes down and child starts to feel
better.
Signs:
- Ear canal may contain blood-tinged
discharge which becomes
mucopurulent.
- Otoscopy: Usually a small TM
perforation (antero-inferior
quadrant of pars tensa)
- TM colour and landmarks return to
normal.
Stage 5: Complications

Undertreatment/Virulence
of organism high

Resolution may not take

place

Disease spreads beyond

middle ear.
Stage 5: Complications

Complications:
• Acute mastoiditis
• Subperiosteal abscess
• Extradural abscess
• Brain abscess
• Labyrinthitis
• Facial nerve palsy
• Meningitis
• Petrositis
• Lateral sinus thrombophlebitis
Stage 5: Complications
 Treatment
1. Antibacterial therapy
• Fever and severe earache
• Ampicillin(50mg/kg/day)qid , amoxicillin(40mg/kg/day) tid/co-trimoxazole
/erythromycin (S. pneumoniae & H. influenzae).
• Minimum of 10 days, until TM and hearing normal.
2. Decongestant nasal drops/oral nasal decongestants
• To relieve eustachian tube oedema & promote ventilation of middle ear.
3. Analgesics & antipyretics
4. Ear toilet
• Sterile cotton buds, antibiotic
5. Dry local heat (relieve pain) – warm olive oil drops are soothing.
6. Myringotomy
• Incise TM to evacuate pus

*ALL CASES OF ASOM SHOULD BE CAREFULLY FOLLOWED UNTIL TM RETURNS TO

NORMAL & CONDUCTIVE DEAFNESS DISAPPEARS
OTITIS MEDIA WITH EFFUSION
(OME)
Definition: Presence of fluid in middle ear without signs and
symptoms of ear infection.

• Aka serous otitis media, secretory otitis media, “glue-ear”

• Insidious onset of accumulation of non-purulent effusion in
middle ear.
• Follows AOM frequently in children.
• Same risk factors as AOM.
Pathogenesis
1. Malfunctioning of Eustachian tube
- Unable to aerate the middle ear & unable to drain the
fluid
- Causes: adenoid hyperplasia, chronic rhinitis & sinusitis,
chronic tonsillitis, tumor of nasopharynx, palatal defects
2. Increased secretory activity of middle ear mucosa
- Causes: allergy (middle ear mucosa acts as shock organ),
viral infection of middle ear, unresolved otitis media
- Can be confirm by biopsy
Pathogenesis
3. Unresolved otitis media
-Inadequate antibiotic therapy
-Low-grade infection lingers on. This acts as stimulus
for mucosa to secrete more fluid

4. Viral infections. Various adeno- and rhinoviruses of

upper respiratory tract may invade middle ear mucosa
and stimulate it to increased secretory activity
Clinical Features
• conductive hearing loss ± tinnitus
- confirm with audiogram and tympanogram
• fullness - blocked ear
• ± pain, low grade fever

•Otoscopy:
• TM dull and opaque with loss of light reflex. May appear yellow or bluish.
• Retracted TM/ Bulging in its posterior part due to effusion
• Meniscus fluid level behind TM/ air bubble may be seen
• Mobility is restricted/ sluggish (pneumatic speculum)
Treatment
• Decongestants. Topical decongestants in the form of nasal
drops, sprays or systemic decongestants help to relieve
oedema of eustachian tube
• Antihistaminic or sometimes steroids may be used in
cases of allergy. If possible, allergen should be found and
desensitization done
• Antibiotics are useful in cases of upper respiratory tract
infections or unresolved acute suppurative otitis media.
• Middle ear aeration repletely perform Valsalva
maneuver, give children chewing gum
• Surgery:
- Myringotomy and aspiration of fluid
- Grommet insertion – provide continued aeration of middle ear.
- Surgical treatment of causative factor (eg. Adenoidectomy,
tonsillectomy)
CHRONIC SUPPURATIVE OTITIS MEDIA
(CSOM)
CSOM
• Long standing infection of a part or whole of middle
ear cleft. (>2 weeks)
• 2 forms of CSOM:

1. Tubotympanic disease (Safe)

2. Atticoantral disease (Unsafe)
Types of CSOM

Tubotympanic disease (TTD) Atticoantral disease (AAD)

• Mucosal disease. • Presence of
• More in the eustachian cholesteatoma in middle
tube and tympanic ear cleft. (cause bone
cavity. erosion)
• Safe type. • More in the
attic/mastoid segment.
• Unsafe/Dangerous type.
Types of CSOM
TUBOTYMPANIC DISEASE (TTD)
AETIOLOGY
1. It is the sequela of acute otitis media leaving behind
a large central perforation. perforation becomes
permenantmiddle ear exposed to dust and other
aero allergent
2. Ascending infections via the eustachian tube from
infected tonsils, adenoids, infected sinuses.
3. Allergy to food such as milk, egg, fish cause
persistent mucoid otorrhea.
Pathology
1. Perforation of pars tensa
2. Middle ear mucosa
• Oedematous and velvety in active disease.
3. Polyp
• Smooth mass of oedematous and inflamed mucosa protruding through
perforation into EAC.
4. Ossicular chain
• Usually intact and mobile but may show some degree of necrosis
5. Tympanosclerosis
• Hyalinisation and subsequent calcification of subepithelial connective
tissue seen in remnants of TM/under mucosa of middle ear
• White chalky deposits
• May interfere with mobility of middle ear structures and cause
conductive deafness.
6. Fibrosis and adhesions
• May further impair mobility of ossicular chain/block eustachian tube.
BACTERIOLOGY
Aerobic organisms
• Pseudomonas aeruginosa, Proteus, Escherichia coli
and Staphylococcus aureus.
Anaerobes organisms
• Bacteroides fragilis and anaerobic Streptococci.

CLINICAL FEATURES
1. Ear discharge
2. Conductive hearing loss
3. Central perforation
4. Middle ear mucosa inflamed (red, edematous and
swollen)
Management
INVESTIGATIONS
• Examination under microscope
• Audiogram (degree and type of hearing loss)
• C&S of ear discharge
• Mastoid X-rays (usually sclerotic but may be
pneumatised with clouding of air cells)
Management
TREATMENT
• Aim: control infection and eliminate ear discharge, correct hearing
loss by surgical means
1. Aural toilet (remove all discharge and debris)
2. Ear drops (antibiotic + steroids) + irrigation with 1.5% acetic acid
3. Systemic antibiotics good in acute execerbation
4. Precautions (Keep ears dry, use ear plug, avoid swimming, don’t
blow nose hard)
5. Treatment of underlying causes (infected tonsils, adenoid, nasal
allergy)
6. Surgical treatment (aural polyp/granulations should be removed
before topical antibiotics applied)
7. Reconstructive surgery (Myringoplasty +/- ossicular
reconstruction)
ATTICOANTRAL DISEASE (AAD)
PATHOLOGY
1. Cholesteatoma
• a cyst composed of keratinized desquamated epithelial cells
occurring in the middle ear, mastoid, and temporal bone.
• Keratinising squamous epithelium(matrix) + central white mass
of keratin debris produced by matrix.
2. Osteitis & granulation tissue
3. Ossicular necrosis
• Destruction may be limited to the long process of incus or may
also involve stapes superstructure, handle of malleus or the
entire ossicular chain.
4. Cholesterol granuloma
• Mass of granulation tissue with foreign body giant cells
surrounding the cholesterol crystals.
• Reaction to longstanding retention of secretions/
haemorrhage.
Clinical Features
SYMPTOMS
 Ear discharge - foul smelling(bone destruction)
 Hearing loss
 Bleeding (from polyp/granulations)
SIGNS
Perforation -
attic/posterosuperior,
marginal
Retraction pocket -
invagination of TM.
Cholesteatoma - pearly
white flakes.
Treatment
SURGICAL (MAINSTAY OF TREATMENT)
• Primary aim is to remove disease and render the ear safe
• 2nd preserve or reconstruct Hearing
2 types procedure
-Canal wall down procedures
-Canal wall up procedures.
• RECONSTRUCTIVE SURGERY
• Hearing can be restored by myringoplasty or tympanoplasty.
CONSERVATIVE TREATMENT
• Limited role but can be tried when cholesteatoma is small and easily
accessible to suction clearance under microscope
• Good for old pt who cannot put under GA and pt who refuse surgery
• Polyps and granulations can also be surgically removed by
cup forceps or cauterized by chemical agents like silver
nitrate or trichloroacetic acid
 Complications
1. Pain. Pain is uncommon in uncomplicated CSOM. Its 9. Ataxia (labyrinthitis or cerebellar
presence is considered serious as it may indicate extradural, abscess).
perisinus or brain abscess. Sometimes, it is due to otitis 10. Abscess round the ear
externa associated with a discharging ear. (mastoiditis).
2. Vertigo. It indicates erosion of lateral semicircular canal It is not uncommon for a patient of
which may progress to labyrinthitis or meningitis. Fistula CSOM, residing in a
test should be performed in all cases. far-flung village, where medical facilities
3. Persistent headache. It is suggestive of an intracranial are poor, to go to a doctor for the first
complication. time, presenting with complications. It
4. Facial weakness indicates erosion of facial canal. then demands urgent attention and
5. A listless child refusing to take feeds and easily goingemergency
to medical or
sleep (extradural abscess). surgical treatment.
6. Fever, nausea and vomiting (intracranial infection).
7. Irritability and neck rigidity (meningitis).
8. Diplopia (Gradenigo syndrome) petrositis
Clinical approach to patient with
ear discharge
Clinical Approach
• Age
• ASOM (Acute Suppurative Otitis Media),
CSOM (Chronic Suppurative Otitis Media) common in children
• Neoplasm common in age 30-50
• Sex
• CSOM more common in boys
• Chief complain
• Side and duration
• HOPI
• Duration
• Side : unilateral/bilateral
• Onset : Acute acute OM, TM perforation, Otitis externa, Furuncle
Insidious CSOM, Cholesteatoma
Recurrent Furuncle
• Progression : Continuous  CSOM
Intermittent ASOM (ask frequency and duration)
• Amount scanty / profuse
• Nature  water, serous, purulent
• Trauma history
• Foul smelling CSOM Ostemyelitis
Associated symptoms
• Ear pain
• Fever
• Pruritus
• Vertigo
• Tinnitus
• hearing loss
Activities that can affect canal or TM
• Swimming
• Insertion of object
• Trauma
• Ear drop
• Antibiotic
• Chloromycetin, Neomycin eczematous otitis externa
• Past History
• URTI, chronic sinusitis, chronic rhinitis dysfunctional Eustachian tube
ASOM CSOM
• Diabetes, immunodeficiency
• Previous surgery in ear, sinus, pharynx
• Ear disease during childhood congenital
Examination
• Pinna
• Tenderness on moving
• Pre auricular
• spreading cellulitis in furuncle and malignant OE
• Post auricular
• lymphadenopathy
• Tragal tenderness
• Furuncle, otomycosis, maglinant OE
• Mastoid tenderness
• CSOM
~end~