Symptoms and Signs – Differential Diagnosis of Ear discharge

Symptoms and Signs – Differential Diagnosis of Ear discharge
Otorrhea, or ear drainage, may be sanguineous (otorrhagia), purulent, clear, or serosanguineous. The onset, duration, and severity offer insights into the underlying reason. This symptom may arise from conditions impacting the external ear canal or middle ear, such as allergies, infections, neoplasms, trauma, and collagen disorders. Otorrhea may manifest independently or in conjunction with additional symptoms, including otalgia.

Medical History and Physical Assessment
Commence your assessment by inquiring when otorrhea commenced and how the patient identified it. Did he cleanse the drainage from the depths of the ear canal, or did he remove it from the auricle? Request a description of the color, consistency, and odor of the drainage from him. Is it transparent, purulent, or sanguineous? Does it manifest in one ear or both ears? Is it constant or sporadic? Inquire how frequently the patient replaces the cotton in his ear used to absorb discharge. Subsequently, investigate related otologic complaints, particularly pain. Is there sensitivity upon movement of the pinna or tragus? Inquire about vertigo, which is not present in conditions affecting the external ear canal. Inquire about tinnitus as well. Subsequently, review the patient's medical history for any recent upper respiratory infections or head injuries. Inquire about his ear-cleaning methods and whether he is a passionate swimmer. Document a history of malignancy, dermatitis, or immunosuppressive therapy.

Concentrate the physical examination on the patient's external ear, middle ear, and tympanic membrane. Examine the uninvolved ear first to avoid cross-contamination if his symptoms are unilateral. Examine the external ear and apply pressure to the tragus and mastoid region to assess for tenderness. Subsequently, insert an otoscope, utilizing the largest speculum that may be easily accommodated into the ear canal. Remove cerumen, pus, or other material from the canal if required. Monitor for edema, erythema, crusts, or polyps.

Examine the tympanic membrane, which should appear as a lustrous, pearl-gray cone. Observe alterations in color, perforation, lack of the typical light reflex (a cone of light positioned at the inferior aspect of the drum), or a distended membrane. Subsequently, assess auditory acuity. Instruct the patient to occlude one ear as you whisper a selection of typical two-syllable syllables toward the unobstructed ear. Position yourself behind him to prevent lip-reading, and request that he reiterate what he perceived.

Execute the Conduct an examination on the alternate ear with distinct terminology. Subsequently, utilize a tuning fork to conduct the Weber and Rinne tests. Conduct a thorough assessment by palpating the patient's neck and the preauricular, parotid, and postauricular (mastoid) regions for lymphadenopathy. Additionally, evaluate the functionality of cranial nerves VII, IX, X, and XI.

Etiological Factors
Aural polyps
Aural polyps may yield malodorous, purulent, and perhaps blood-tinged discharge. Occlusion of the external ear canal by polyps may result in partial hearing loss.

Fracture of the basilar skull
A basilar skull fracture may result in otorrhea that is either clear and watery, indicating cerebrospinal fluid (CSF) leaking and testing positive for glucose, or bloody, indicating hemorrhage. Occasionally, examination uncovers blood behind the tympanic membrane. Otorrhea may be associated with auditory impairment, cerebrospinal fluid or sanguineous rhinorrhea, periorbital ecchymosis (raccoon eyes), and mastoid ecchymosis (Battle's sign). Cranial nerve palsies, diminished consciousness, and cephalalgia are further prevalent observations.

Epidural abscess
An epidural abscess is characterized by abundant, creamy otorrhea, persistent throbbing ear discomfort, fever, and a temporal or temporoparietal headache on the same side.
Infectious myringitis
Acute infectious myringitis is characterized by the emergence of tiny, reddish, blood-filled vesicles in the external ear canal, tympanic membrane, and infrequently, the middle ear. The spontaneous rupture of these blebs results in serosanguineous otorrhea. Additional symptoms encompass intense otalgia, sensitivity over the mastoid process, and, infrequently, pyrexia and auditory impairment. Chronic infected myringitis results in purulent otorrhea, itching, and progressive hearing loss.

External otitis
Acute otitis externa, referred to as swimmer’s ear, typically results in purulent, yellow, viscous, malodorous otorrhea. Examination may disclose white-green detritus in the external auditory canal. Accompanying observations consist of edema, erythema, discomfort, and pruritus of the auricle and external auditory canal; pronounced soreness upon manipulation of the mastoid, tragus, mouth, or jaw; tenderness and swelling of adjacent lymph nodes; and partial conductive hearing impairment. The patient may also experience a low-grade fever and a headache on the same side as the afflicted ear. Chronic otitis externa typically results in minimal, intermittent otorrhea that may be serous or purulent and perhaps malodorous. The principal symptom, Nevertheless, there is pruritus. Associated observations encompass edema and mild erythema.

Malignant otitis externa, a life-threatening condition, generates debris in the ear canal that can accumulate on the tympanic membrane, resulting in intense pain, particularly during manipulation of the tragus or auricle. This acute bacterial infection is predominantly observed in individuals with diabetes and those who are immunosuppressed, and it may also result in pruritus, tinnitus, and even unilateral hearing loss.

Middle ear infection
In acute otitis media, tympanic membrane rupture results in bloody, purulent otorrhea and alleviates persistent or sporadic ear pain. A conductive hearing loss generally deteriorates over a span of several hours. In cases of acute suppurative otitis media, the patient may present with manifestations indicative of an upper respiratory infection, including pharyngitis, cough, rhinorrhea, and cephalalgia. Additional symptoms encompass vertigo, pyrexia, nausea, and emesis.

Chronic otitis media results in intermittent, purulent, malodorous otorrhea typically linked to tympanic membrane perforation. Conductive hearing loss develops progressively and may be associated with pain, nausea, and vertigo. Psychological injury. Hemorrhagic otorrhea may occur due to trauma, including impact to the external ear, the presence of a foreign object in the ear, or barotrauma. Typically, hemorrhaging is minimal or moderate and may be associated with partial auditory impairment.

Malignant tumor
Squamous cell carcinoma of the external ear results in purulent otorrhea accompanied by pruritus; profound, penetrating otalgia; auditory impairment; and, in advanced stages, facial paralysis. In squamous cell carcinoma of the middle ear, hematic otorrhea manifests early, usually accompanied by auditory impairment on the afflicted side. Analgesia and facial paralysis are late manifestations.

Administer warm, wet compresses, heating pads, or hot water bottles to the patient's ears to alleviate inflammation and discomfort. Utilize cotton wicks to delicately cleanse the draining ear or to administer topical medications. Maintain eardrops at ambient temperature; the use of cold eardrops may induce vertigo. Should the patient possess hearing impairments, confirm his comprehension of all explanations, utilizing written communication if required.


Advise the patient on proper techniques for nasal expulsion and auricular hygiene. Emphasize the Utilization of earplugs during swimming. Detail the signs and symptoms that the patient ought to communicate.

When inspecting or cleansing a child's ear, note that the auditory canal is oriented horizontally, necessitating the pinna to be moved downward and backward. Secure a youngster during an ear examination by positioning them on a parent's lap with the ear to be assessed oriented towards you. Instruct him to place one arm around the parent's waist while the other rests at his side, and then request that the adult secures the youngster in position. If you are alone with the youngster, instruct him to lie prone with his arms at his sides and his head twisted so that the affected ear is oriented towards the ceiling. Lean over him, immobilizing his upper torso with your elbows and upper arms. Perforation of the tympanic membrane due to otitis media is the predominant cause of otorrhea in newborns and young children. Children frequently introduce strange objects into their ears, leading to infection, discomfort, and purulent discharge.