Otorrhea

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Otorrhea or “runny ears” is a common pediatric problem that is benign in most cases but can signify a significant underlying disease.

Otorrhea can result from external ear canal pathology or middle ear disease with tympanic membrane perforation. It can also occur after a significant skull injury. Otorrhea in the setting of a traumatized or immunocompromised patient may indicate a serious life-threatening condition, and so prompt and thorough evaluation is necessary if trauma has not been ruled out. The physical examination and the history will differentiate among most causes of otorrhea in children.

 

Evaluation

History:
HPI encompassing full symptomology should be recorded, paying particular attention to the features of the drainage: color, frequency, onset, duration, amount, and odor. Important associated symptoms of otorrhea include pain, pruritus, decreased hearing, vertigo, and tinnitus. Patients should be questioned about activities that can affect the canal or tympanic membrane (e.g., swimming; insertion of objects, including cotton swabs; use of ear drops). Head trauma sufficient to cause a CSF leak should be readily apparent.

PMH should note any previous known ear disorders, recurrent ear infections, ear surgery (particularly tympanostomy tube placement), and diabetes or any possible immunodeficiency. Previous treatment of ear drainage could indicate a chronic condition necessitating more comprehensive treatment.

ROS should seek symptoms of cranial nerve deficit and systemic symptoms suggesting systemic disease such as Wegener's granulomatosis (eg, nasal discharge, cough, joint pains).

Physical examination:
Examination begins with a review of vital signs for fever, and visual inspection for any obvious head trauma. Intracranial complications of AOM are particularly a concern in children who appear ill. These complications include meningitis, epidural abscess, brain abscess, lateral sinus thrombosis, cavernous sinus thrombosis, subdural empyema, and carotid artery thrombosis. Patients with these illnesses usually develop fever and, over time, a toxic appearance; a few may manifest cranial nerve deficits, especially cranial nerve VII (facial nerve) and less commonly cranial nerve VI.

Ear and surrounding tissues (particularly the area over the mastoid) are inspected for erythema and edema. The pinna is pulled and the tragus is pushed gently to see whether pain is worsened. Ear canal is inspected with an otoscope; the character of discharge and presence of canal lesions, granulation tissue, tympanostomy tubes or foreign body are noted. Edema and discharge may block visualization of all but the distal canal (irrigation should not be used in case there is a TM perforation), but when possible, the TM is inspected for inflammation, perforation, distortion, and signs of cholesteatoma (eg, canal debris, polypoid mass from TM).

When the ear canal is severely swollen at the meatus (as in severe otitis externa) or there is copious drainage, careful suctioning can permit an adequate examination and also allow treatment such as application of drops.

The cranial nerves are tested. The nasal mucosa is examined for raised, granular lesions, and the skin is inspected for vasculitic lesions.

 

Red flags

 The following findings are of particular concern:

  • Recent major head trauma
  • Any cranial nerve dysfunction (including sensorineural hearing loss)
  • Fever
  • Erythema of ear or periauricular tissue
  • Diabetes or immunodeficiency

 

Diagnosis

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  1. Acute otitis media with or without rupture of the tympanic membrane
  2. Drainage through tympanostomy tube secondary to infection, swimming, or bathing
  3. Otitis externa (“swimmer’s ear”)
  4. Trauma/foreign body
  5. Basilar skull fracture (temporal bone)
  6. Spontaneous CSF otorrhea (if chronic; meningitis>1x  can be indicative)
  7. Boil or dermatitis of the canal
  8. Immunodeficiency state and opportunistic organisms including tuberculosis
  9. Chronic drainage – mastoiditis and cholesteatoma
  10. Neoplasm (RARE)
  11. Langerhans cell histiocytosis

Many cases are clear after clinical evaluation. Otorrhea in children is often caused by one of several more benign diseases. Clinical findings with cleansing of debris will differentiate among most of these etiologies. Otoscopic examination can usually diagnose perforated TM, external otitis media, foreign body, or other uncomplicated sources of otorrhea. Other findings are less specific but indicate a more serious problem that involves more than a localized external ear or middle ear disorder. These include vertigo and tinnitus (disorder of the inner ear), cranial nerve deficits (disorder involving the skull base), or skull trauma. If CSF leakage is in question, fluid discharge can be sent to the lab for glucose or β2-transferrin (present in CSF but not in other types of discharge) testing. Patients without an obvious etiology on examination require audiogram and CT of the temporal bone or gadolinium-enhanced MRI. Biopsy should be considered when auditory canal granulation tissue is present. Ear canal cancer occurs far less frequently than auricular cancer, although the presentation and behavior are more sinister. In the early stages it is often indistinguishable from external otitis. In addition, neuroblastoma and rhabdomyosarcoma may manifest as auditory canal tumors in children.

 

Treatment

Treatment is dependent upon diagnosis. Patients who are ill appearing or have otorrhea after head trauma require aggressive efforts to diagnose and treat potential life threatening causes of otorrhea (basilar skull fracture, necrotizing otitis externa, infectious complications of acute otitis media). Referral to neurosurgery is mandatory. Children with persistent or recurrent otorrhea that does not respond easily to appropriate treatment should be referred to an otolaryngologist. In most cases, the cause is more benign and thus more easily treated. Treatment can be as simple as removal of foreign body, but even this can be complex if the foreign body is an insect, a sharp object, or a battery. In the most common of cases, ear drops will treat external otitis and oral antibiotics are administered for acute otitis media.

 

Summary

Otorrhea is drainage of liquid from the ear. Otorrhea results from external ear canal pathology, middle ear disease with tympanic membrane perforation, or skull trauma. Timing (acute vs. chronic) and duration of drainage can be used to rule in/out traumatic and infectious causes. When fluid is appreciated on exam, the consistency of the drainage can be a helpful diagnostic tool:

  1. Clear – CSF via fracture of temporal bone, spontaneous if chronic leak, water from recent swimming/bathing
  2. Bloody – trauma to the canal (cleaning with q-tips, foreign body) or eardrum (auditory barotrauma) or skull fracture
  3. Purulent – acute/chronic otitis media, auditory canal infection, perforated TM
  4. Waxy – benign

Treatment is dependent upon diagnosis. Severe acute otitis media is treated with oral antibiotics; some authorities suggest use of topical antibiotics in addition to oral if tubes are present. Otitis externa is particularly painful and requires topical antibiotics and sometimes pain control. Chronic drainage may be treated with oral antibiotics, but if there is no response the patient needs to be seen by ENT. Emergency referral to neurosurgery is necessary for any indications of skull trauma.

 

References

  1. Evaluation of otorrhea (ear discharge) in children. UpToDate. February 2010.
  2. Tucci D. Otorrhea: Approach to the Patient with Ear Problems. The Merck Manuals Online Medical Library: January 2009.
  3. Schwartz R. and Bahadori R. What to do for runny ears. Contemporary Pediatrics: May 1999.
  4. Schroeder A, Darrow D. Management of the draining ear in children. Pediatr Ann. 2004; 33(12):843-852.
  5. Isaacson G.  Diagnosis of Pediatric Cholesteatoma. Pediatrics 2007 Sept

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