Evaluation of otorrhea (ear discharge) in children

Evaluation of otorrhea (ear discharge) in children

Authors
Christopher G Strother, MD
Karin Sadow, MD
Section Editor
Stephen J Teach, MD, MPH
Deputy Editor
James F Wiley, II, MD, MPH
Disclosures
All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Oct 2013. | This topic last updated: Dec 6, 2012.

INTRODUCTION — Otorrhea means drainage of liquid from the ear. Otorrhea results
from external ear canal pathology or middle ear disease with tympanic membrane
perforation. The physical examination and the history will differentiate among most
causes of otorrhea in children.

The evaluation of otorrhea in children is reviewed here. The approach to ear pain is
discussed separately. (See "Evaluation of earache in children" .)

DIFFERENTIAL DIAGNOSIS — The table provides a list of etiologies for otorrhea in

children ( table 1 ).

Life-threatening conditions — Otorrhea in the setting of a traumatized or

immunocompromised patient may indicate a serious life-threatening condition.

Traumatic cerebrospinal fluid otorrhea — Cerebral spinal fluid (CSF) otorrhea is a

serious sign in the setting of head trauma. If any ear discharge is noted after serious
head trauma, particularly clear or bloody discharge, the patient should undergo
evaluation for CSF otorrhea caused by a basilar temporal skull fracture. (See "Evaluation
and management of middle ear trauma", section on 'Evaluation of ear or nose
drainage' and "Skull fractures in children", section on 'Basilar skull fractures' .)

Hemorrhagic otorrhea may also arise from middle ear trauma caused by a direct blow to
the ear, auditory barotrauma, or intrusion of a foreign body into the external ear canal.
(See "Evaluation and management of middle ear trauma" and "Ear barotrauma" .)

Infectious complications of acute otitis media — Because the mastoid air cells are
connected to the distal end of the middle ear through a small canal or antrum, most
episodes of acute otitis media (AOM) are associated with some inflammation of the
mastoid. In rare cases, resolution of the mastoid infection does not occur, and acute
mastoiditis develops with pus filling the air cells. The child with mastoiditis will have
painful swelling behind the ear that typically pushes the pinna forward. (See "Acute
mastoiditis in children: Clinical features and diagnosis" .)

Other intratemporal complications that occur by contiguous spread of infection include

petrositis (Gradenigo syndrome with sixth nerve palsy) and labyrinthitis.

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. (See "Acute otitis media in children:
Epidemiology, microbiology, clinical manifestations, and complications", section on
'Intracranial complications' .)

Necrotizing otitis externa — Also called malignant external otitis, this is a

complication of bacterial otitis externa. Infection of the skin gives way to deeper seeding
of cartilage, tissue, and bone. As the infection advances, osteomyelitis of the base of the
skull, temporomandibular joint osteomyelitis, brain abscess, and generalized bacterial
sepsis can develop. Although most commonly seen in the elderly and adults with
diabetes mellitus, immunocompromised children (eg, cancer patients on chemotherapy
or HIV-infected patients) are at risk.

Patients with malignant external otitis classically present with otorrhea and exquisite
otalgia which are not responsive to topical measures used to treat simple external otitis.
The pain is generally more severe than that found in simple external otitis, although the
two may be difficult to distinguish in their early stages. The pain in malignant external
otitis tends to extend into the temporomandibular joint, resulting in pain with chewing.

On physical examination, purulent otorrhea is seen in more than half of cases, and
ipsilateral lower motor neuron facial nerve palsy can be present as well. Granulation
tissue may be visible in the inferior portion of the external auditory canal at the bone-
cartilage junction (at the site of Santorini's fissures).This finding may be absent in
atypical patients (eg, HIV-infected patients and children). Early empiric antibiotic
therapy and otolaryngology consultation are essential to good outcomes.
(See "Malignant (necrotizing) external otitis" .)

Neoplasm — Cancer is a rare cause of otorrhea but should be considered in patients

with abnormal tissue growth in the ear canal or a lack of response to prolonged external
otitis treatment. These patients warrant prompt referral to an ear, nose, and throat
(ENT) specialist with pediatric expertise.

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, rhabdomyosarcoma and
neuroblastoma may manifest as auditory canal tumors in children. (See"External otitis:
Pathogenesis, clinical features, and diagnosis", section on 'Carcinoma of the ear
canal' and "Clinical presentation, diagnosis, and staging evaluation of neuroblastoma",
section on 'Metastatic disease' .)

Common conditions — 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.

Bacterial otitis externa — Acute bacterial external otitis, often called "swimmer's
ear," is an infectious inflammation of the external auditory canal. History often includes
either water exposure or instrumentation with damage to the outer ear canal (such as
cleaning with cotton swabs or finger scratching). Common symptoms include pain,
pruritus, and hearing loss. Minor trauma to the canal's protective skin barrier and
protective cerumen layer allows for bacterial overgrowth. Otitis externa is most
commonly caused by Pseudomonas aeruginosa, although Staphylococcus aureus,
Staphylococcus epidermidis, polymicrobial and anaerobic infections can occur.
(See "Patient information: External otitis (including swimmer's ear) (Beyond the
Basics)" and"External otitis: Pathogenesis, clinical features, and diagnosis", section on
'Diagnosis' .)

On physical examination, moderate to severe pain with minor tragus manipulation or

pulling on the auricle is classic. An erythematous, edematous ear canal with cellular
debris is seen. Since the middle ear is not necessarily involved in external otitis, there
may not be any middle ear effusion or purulent otitis media. When visible, the tympanic
membrane (TM) itself is typically erythematous or covered with debris. Often the
membrane is difficult to see due to edematous narrowing of the canal. Otorrhea is
purulent, white to yellow, and may dry to a crust.

Patients with severe forms of otitis externa may also have fever, regional
lymphadenopathy, or erythema of the pinna. If the pinna is infected, very aggressive
treatment may be necessary such as admission for intravenous antibiotics, topical soaks,
and surgical debridement. It is important to make the distinction between a generalized
cellulitis of the skin of the pinna and a more serious cartilage infection such as
perichondritis or chondritis. This distinction may be made by inspecting the lobule, which
has no cartilage. If the lobule is spared, but the rest of the pinna is erythematous, this
suggests involvement of the pinna cartilage. (See "Other Pseudomonas aeruginosa
infections", section on 'Perichondritis' and "External otitis: Pathogenesis, clinical features,
and diagnosis", section on 'Malignant external otitis' .)

Foreign body — Ear foreign bodies (FBs) may cause otorrhea if they are long standing
or consist of highly irritating substances. The history may or may not indicate their
presence.

Typical foreign bodies include:

 Toys or small objects placed in the ear by toddlers, or placed into younger
sibling's ears
 Insects, although they are often so irritating that removal occurs before otorrhea
develops
 Food material, especially nuts with irritating oils that can cause a significant
reaction
 Button batteries (often used in small electronic devices such as hearing aids)
 Expelled tympanostomy tube with granulation tissue and bloody otorrhea
(see 'Tympanostomy tube drainage' below)

Button batteries require emergent removal because pressure necrosis and/or severe
burns from residual electric current or leakage of caustic contents may rapidly lead to
extensive damage to adjacent structures.

Otoscopy is diagnostic. However, cerumen buildup or otorrhea may obscure the object,
and cleaning may be necessary before the FB can be seen. Most ear FBs that do not
cause otorrhea can be removed using simple techniques in the emergency department or
primary care setting without referral to an ENT specialist. However, complications do
result from multiple manipulations, and an ENT consult should be called when in doubt
or when necessary visualization and removal equipment are not available.
In patients with FBs that cause otorrhea, visualization and removal can be extremely
difficult and must be done with care. Unless the clinician ensures visualization of the
object and has the proper tools and setting (including the ability to restrain and possibly
sedate the child), referral to an ENT specialist with audiometry is warranted.
(See "Diagnosis and management of foreign bodies of the outer ear" and "Procedural
sedation in children outside of the operating room" .)

Acute otitis media — Occasionally, the tympanic membrane will rupture in the course
of acute otitis media. This is usually associated with ear pain and fever of relatively short
duration, followed by pain relief associated with the onset of otorrhea. The drainage
often has a clear or white appearance. By the time the patient is seen, the perforation
may have healed, but the drainage may continue for some time, especially if otitis
externa has developed. (See 'Bacterial otitis externa' above.)

Often the perforation itself may not be visible on otoscopy because the otorrhea
obscures visualization of the tympanic membrane (TM) or the perforation has rapidly
resealed. When seen, the TM typically has abnormal appearance and lack of mobility on
pneumatic otoscopy. If the perforation is of recent origin, it generally heals
spontaneously once the infection resolves. (See "Acute otitis media in children:
Epidemiology, microbiology, clinical manifestations, and complications", section on 'TM
perforation' and "Acute otitis media in children: Treatment" .)

Chronic suppurative otitis media — Chronic suppurative otitis media (CSOM), or

chronic otomastoiditis, is a perforation of the eardrum with chronic drainage from the
middle ear cleft. This condition is more frequently seen in children who lack access to
health care and, thus, do not have timely diagnosis and treatment of acute otitis media.
It should not be confused with longstanding otitis media with effusion (OME, or "serous"
otitis media), or persistent acute otitis media, both of which involve an intact tympanic
membrane and no drainage. (See "Otitis media with effusion (serous otitis media) in
children", section on 'Clinical features' .)

CSOM is often painless. On examination, a debris-filled canal is noted. The discharge is

often white to yellow, and mixed with soft cerumen. Pseudomonas aeruginosa and
Staphylococcus aureus are common pathogens. Treatment typically consists of topical
antibiotic ear drops, with topical quinolones being the best studied treatment choice.
Parenteral antibiotic administration guided by culture of the ear
discharge and/or tympanomastoidectomy may be necessary in refractory cases, though
the evidence for superiority of systemic antibiotics over topical quinolone antibiotics is
mixed and not convincing [ 1]. These refractory cases should be pursued in consultation
with an ENT specialist.

Cerumen — Annoying to many parents, but generally harmless, some children have
thin cerumen that can present as ear drainage. In general, cerumen is only a problem if
it is impacted or if it precludes examination of the eardrum. In such cases, removal may
be necessary, but precautions should be taken when instrumenting the ear canal.
(See 'External auditory canal cleaning' below.)

Tympanostomy tube drainage — Ten to 30 percent of children with tympanostomy

tubes will have at least one episode of acute otorrhea while their tympanostomy tubes
are in place, either immediately postoperatively or during an episode of acute otitis
media. The drainage is usually foul smelling, mucoid, and may be mixed with blood. It is
generally treated with antibiotic drops. Suction cleaning of the ear canal may be needed
for drops to be effective. Rarely, systemic antibiotics or even mastoid surgery is needed
if the drainage is persistent. (See "Prevention and management of tympanostomy tube
otorrhea in children", section on 'Treatment' .)

Other conditions — Less commonly, otorrhea may arise from the following conditions:

Contact dermatitis — Topical medications or cosmetics may cause local irritation and
inflammation with ear drainage. A typical history reveals the offending agent being used,
often for a pre-existing condition such as otitis externa or cerumen impaction. Pruritus,
pain, and inflammation on examination accompany the otorrhea. Treatment consists of
topical corticosteroids and avoidance of the allergen. (See "External otitis: Pathogenesis,
clinical features, and diagnosis", section on 'Contact dermatitis' .)

Bullous myringitis — Often associated with respiratory symptoms or acute otitis

media, bullous myringitis describes serous liquid-filled blisters, or "bullae," on the
tympanic membrane. When the bullae rupture, thin bloody otorrhea may occur and pain
is often relieved. The external ear canal is not typically involved. (See "Acute otitis media
in children: Epidemiology, microbiology, clinical manifestations, and complications",
section on 'Bullous myringitis' .)

Granulation tissue — Granulation tissue can develop in a number of conditions and

can be associated with otorrhea. As mentioned previously, this tissue can accumulate
around a foreign body (such as a tympanostomy tube). It can also be seen in
granulomatous disease (such as Langerhans cell histiocytosis), or in chronic
inflammatory conditions (such as chronic otitis media). The rich vascular supply can also
lead to leakage of lymphatic fluid [ 2 ]. (See "Clinical manifestations, pathologic
features, and diagnosis of Langerhans cell histiocytosis" .)

Polyps — Polyps in the external ear canal may occur in response to an inflammatory
reaction or infection such as chronic otitis media, cholesteatoma, or retained foreign
body (eg, expelled tympanostomy tube) [ 3 ]. Rarely, they may arise from a tumor (eg,
Langerhans Cell Histiocytosis, teratoma, neoplasm). Polyps create bloody or serous
otorrhea, generally when manipulated, similar to granulomas. Ear polyps may resolve
rapidly with topical antibiotic and/or anti-inflammatory therapy. However, if drainage
persists for more than two to three weeks, the child should be referred to an ENT
specialist with pediatric expertise [ 4 ].

Otomycosis — Otomycosis is a fungal infection of the external auditory canal and a

common reason for external otitis treatment failure. Patients with fungal external otitis
most commonly report itching, a feeling that something is in the ear canal, discomfort,
and discharge. Otorrhea is generally thick and purulent. Deep seated itching is the most
troublesome symptom; pain is less intense than with bacterial otitis externa. Fungal
organisms have a very characteristic appearance in the ear canal, especially under
magnified vision ( picture 1 ). The clinical manifestations and treatment of otomycosis
are discussed in more detail separately. (See "External otitis: Pathogenesis, clinical
features, and diagnosis", section on 'Otomycosis' .)

First branchial cleft cyst — The first branchial pouch arises in the pharynx and
extends laterally and cephalad to contact the first branchial cleft, forming the eustachian
tube. Rarely, congenitally anomalous first branchial cleft cysts may drain into the
external ear canal. A mass in the periauricular region may suggest this diagnosis in the
face of chronic drainage with a normal tympanic membrane.
Cholesteatoma — A cholesteatoma (sometimes called a keratoma) is an abnormal
growth of squamous epithelium. These can occur in the middle ear and mastoid (middle
ear cholesteatoma) ( picture 2 and picture 3 ), or more rarely, in the ear canal itself
(external ear canal cholesteatoma). It may progressively enlarge to surround and
destroy the ossicles, resulting in conductive hearing loss. Hearing loss also may occur if
the cholesteatoma obstructs the eustachian tube orifice, leading to middle ear effusion.
Surgical therapy is required for most cholesteatomas. (See "Cholesteatoma in
children" .)

Keratosis obturans — Keratosis obturans is an accumulation of desquamated keratin

in the external auditory meatus [ 5,6 ]. Unlike cholesteatoma, keratosis obturans is
associated with an expanded ear canal as keratin is shed from the complete
circumference of the canal, and does not cause osteonecrosis. When compared to
cholesteatoma, keratosis obturans is generally more acute and painful, produces less
otorrhea, and generally occurs in younger patients. It can often be managed with
removal of the keratin plug, antibiotic ear drops, and periodic follow-up to remove any
reaccumulated debris. Operative care is typically not needed.

Spontaneous cerebral spinal fluid otorrhea — In addition to basilar skull fractures

from head trauma, cerebrospinal fluid (CSF) otorrhea may also occur spontaneously
through tegmen tympani defects in the floor of the temporal bone. These defects should
be suspected in cases of persistent otorrhea after the more common causes have
already been excluded or in any child with more than one episode of meningitis. High
resolution computed tomography (CT) with thin cuts through the temporal bone provides
a noninvasive means of diagnosis [ 7 ].

HISTORY — The following historical features should be sought in patients with

otorrhea:

 Features of drainage – Onset, duration, color, and consistency help distinguish

among the etiologies of otorrhea. (See 'Physical findings' below.)
 Fever – Fever suggests the presence of acute middle ear infection or necrotizing
external otitis.
 Pain – A painful ear makes benign chronic tympanic membrane perforation less
likely. Pain with manipulation of the outer ear signals external canal
inflammation (eg, otitis externa, foreign body).
 Pruritus – Itching is a prominent feature of otitis externa (including otomycosis),
allergic dermatitis, and ear foreign body.
 Swimming history – Excessive water exposure is a common factor in the
development of otitis externa. (See 'Bacterial otitis externa' above.)
 Trauma – Otorrhea following significant head injury requires evaluation for
cerebrospinal fluid leakage. Minor external trauma such as cleaning with cotton
swabs or fingers may lead to bacterial otitis externa. (See 'Traumatic
cerebrospinal fluid otorrhea' above and 'Bacterial otitis externa' above.)
 Perforation – A perforation of the TM may be traumatic, infectious, or surgical in
origin (tubes). Any history of prior perforation of the tympanic membrane is
important.
 Medication usage – Topical medications, especially those
containing neomycin , benzocaine , or propylene glycol can trigger a contact
dermatitis of the external auditory canal. Other potential allergens include new
cosmetics, ointments, and certain outdoor plants (eg, poison ivy).
(See 'Contact dermatitis' above.)
  Previous treatments – A draining ear that persists despite antibiotic treatment
may indicate chronic suppurative otitis, otomycosis, or noninfectious causes of
otorrhea.

PHYSICAL EXAMINATION — Examination of the ear requires inspection of the auricle

and surrounding area, otoscopy of the external canal, tympanic membrane, and middle
ear, and, in patients without obvious tympanic membrane perforation, assessment of
tympanic membrane function by pneumatic otoscopy ( movie 1 ). In children with
otorrhea, the external auditory canal is often filled with debris and requires cleaning to
allow proper visualization.

External auditory canal cleaning — In most cases, no cleaning is necessary to make

a diagnosis of otitis externa or otitis media with perforation. Not infrequently, however,
removal of a small amount of debris enhances the view of the examiner, and this can be
achieved using a cotton pledget wrapped tightly around a curette or a wick to soak up
excess fluid. Less often, cleaning through a standard otoscope head may be required to
eliminate profuse, thick exudate totally obscuring the view of the examiner, using a
suction catheter or careful curettage. Care must be used when curetting so that
iatrogenic canal or tympanic membrane trauma does not occur. Thorough cleaning is
best done under direct visualization with use of either an otoscope with an operating
head or an otologic microscope.

Some practitioners will use irrigation to remove cerumen, but this should only be done if
a patient is known to have an intact tympanic membrane. Otherwise, irrigation of a
draining ear is potentially dangerous and should not be performed.

Physical findings — Patient examination should focus on the following findings:

 Head trauma – Any obvious head trauma or signs of basilar skull fracture (eg,
raccoon eyes ( picture 4 ), Battle sign ( picture 5 )) should raise suspicion for
cerebrospinal fluid otorrhea. (See 'Traumatic cerebrospinal fluid
otorrhea' above.)
 Tragal motion tenderness – Pain with manipulation of the tragus or gentle
traction on the auricle of the outer ear is a classic sign of bacterial otitis
externa. However, some pain with manipulation may be present with any
condition that generates inflammation of the external canal. (See 'Bacterial
otitis externa' above.)
 Foreign body – A foreign body (FB) found in the canal may be the source of a
child's otorrhea and requires time to cause drainage. A child rarely may place
something in the ear in an attempt to relieve symptoms from a pre-existing ear
condition. Thus, after removal of the foreign body, careful otoscopic evaluation
is important to exclude other coincidental disease or complications, such as
tympanic membrane perforation. Care must be taken not to cause further
injury during FB removal; any FB that is difficult to remove should be referred
to an ENT specialist. (See 'Foreign body'above.)
 Organic mass or polyp – Polypoid masses or granulomas most often arise in
response to chronic otitis media, foreign bodies in the external ear canal, or
cholesteatoma. Rarely, they may arise from a neoplastic process.
(See 'Polyps' above and 'Neoplasm' above.)
 Quality of discharge – Thin white debris-filled discharge is typical of bacterial
otitis externa. Tympanic perforation generally leads to a mucous discharge as
does contact dermatitis. CSF otorrhea is a clear or thin bloody discharge that
may be mistaken for more benign serous fluid. Purulent discharge can be from
severe irritation, foreign body, middle ear infection, or severe external canal
 infections. Blood-tinged discharge is more likely caused by trauma, foreign
body, granuloma, or carcinoma.
 Inflammation – Inflammation of the tympanic membrane is indicative of middle
ear pathology. Inflammation of the external canal can occur with many
conditions, but it is less likely with isolated middle ear infections with or
without TM perforations. An edematous, erythematous external canal with
debris and a generally clear tympanic membrane is typical of bacterial otitis
externa.
 Tympanic membrane – The tympanic membrane should be carefully inspected for
signs of middle ear infection, such as injection, dullness, and bulging.
Perforation, bullae, and evidence of trauma are additional important findings.
(See "Acute otitis media in children: Diagnosis", section on
'Otoscopy' and "Evaluation and management of middle ear trauma", section on
'Findings of middle ear injury' .)

ANCILLARY STUDIES — History and physical examination are sufficient to diagnose

and manage most causes of otorrhea in children.

Culture of ear drainage — Culture of the external ear canal in otorrhea is rarely
helpful, as Pseudomonas species are commonly identified with or without local infection.
It is also quite difficult to obtain samples from the middle ear that are not contaminated
by external canal flora. In addition, culture rarely changes management decisions in
children with otorrhea.

Indications for culture of ear drainage include:

 Suspected necrotizing otitis externa

 Otitis media with chronic drainage, where previous treatment has failed

When ear drainage culture is needed, an otolaryngology consultation is often necessary

to obtain a proper specimen [ 8 ].

Testing for cerebrospinal fluid otorrhea — To test for cerebrospinal fluid (CSF)
leakage, the clinician may perform a quick bedside test by placing a drop of ear drainage
on filter paper (coffee filter or paper towel). A rapidly advancing "halo" or ring of clear
fluid around red blood defines a positive test. However, the halo test does NOT
differentiate among CSF, saline, saliva, and other clear fluids and has not been formally
studied in a clinical setting.

Alternatively, the clinician may test the ear or nose drainage for beta2 transferrin, a
desialylated form of the protein, transferrin, which is almost exclusively found in CSF.
This test is not available at many institutions.

Urine dipsticks have also been used to determine the presence of CSF by checking for
the presence of glucose. However, this approach is NOT reliable because both blood and
CSF contain glucose.

When in doubt about the presence of a CSF leak, it is best to obtain urgent neurosurgical
consultation. (See "Evaluation and management of middle ear trauma", section on
'Evaluation of ear or nose drainage' .)

Computed tomography — The clinician should obtain specialized computed

tomography of the head with thin cuts through the temporal bone, middle ear, and otic
capsule when it is necessary to evaluate patients for the following diagnoses:
  Basilar skull fracture with cerebrospinal fluid leakage
 Spontaneous cerebrospinal fluid leakage
 Necrotizing otitis externa
 Cholesteatoma
 External auditory canal mass or chronic polyps

Tissue biopsy — Patients with chronic external auditory masses may require tissue
biopsy by an ENT specialist with pediatric expertise to establish a diagnosis.
(See 'Neoplasm' above and 'Polyps' above.)

APPROACH — The initial evaluation should be focused on life-threatening causes of

otorrhea ( algorithm 1 ). In a stable, non-toxic patient, a systematic approach should
start with a thorough history. Careful examination of the outer ear, external canal, and
tympanic membrane should then reveal the diagnosis ( algorithm 2 and algorithm 3 ).

Life-threatening conditions — Children with otorrhea and severe head trauma

require evaluation and management of presumed basilar skull fracture with cerebrospinal
fluid otorrhea ( algorithm 1 ). (See 'Traumatic cerebrospinal fluid otorrhea' above.)

Children with fever and ill appearance warrant rapid assessment for infectious
complications of acute otitis media, and necrotizing otitis externa. (See 'Life-threatening
conditions' above.)

Chronic bloody otorrhea in children with an auditory external canal mass may herald the
presence of a primary or metastatic neoplasm. (See 'Neoplasm'above.)

Non-toxic children — History and physical examination should be sufficient to

establish a diagnosis for otorrhea in most children.

Non-inflamed external canal — An external canal that appears pink, non-edematous,

and non-inflamed indicates likely tympanic membrane or middle ear pathology
( algorithm 3 ). On examination of the tympanic membrane, bullous myringitis appears
as multiple intact or ruptured blisters on the membrane itself, with possible middle ear
inflammation behind. Granular myringitis can also be diagnosed on examination with
visualization of the typical vascular, friable mass. A perforated tympanic membrane
makes middle ear pathology the most likely source of the otorrhea.

Debris in acute otitis media with perforation may make visualization of the tympanic
membrane difficult, so other signs of otitis media such as fever and pain preceding the
drainage may lead to the diagnosis of acute otitis media with perforation. A non-inflamed
tympanic membrane with serous drainage through a perforation is likely chronic serous
otitis media (CSOM), especially in an otherwise asymptomatic child. Although extremely
rare, spontaneous CSF otorrhea has been described and should be considered when
other more common causes of otorrhea have been excluded.

Inflamed external canal — An inflamed, edematous canal is typically associated with

diseases external to the tympanic membrane ( algorithm 2 ). After carefully clearing
debris as needed, the examiner should check for a foreign body. A nonorganic foreign
body can cause otorrhea when associated with concurrent irritation and inflammation. An
organic appearing foreign body or growth in the ear suggests an inflammatory
granuloma, polyp, otomycosis, carcinoma, or cholesteatoma. These masses each have
their own characteristic appearance as described above.
An inflamed, edematous, debris-filled canal with no foreign body is typical of contact
dermatitis and otitis externa. History of moisture exposure or minor trauma
differentiates infectious otitis externa from contact dermatitis, which is associated with
exposure of the ear to some topical medications, cosmetics, or plants. Otitis externa also
tends to be more painful with outer ear manipulation, though contact dermatitis can
become painful when severe as well. Pruritus is typical with both diagnoses. The clinician
should carefully check for pinna and cartilaginous involvement of severe otitis externa.

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education

materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are
written in plain language, at the 5 th to 6 th grade reading level, and they answer the four
or five key questions a patient might have about a given condition. These articles are
best for patients who want a general overview and who prefer short, easy-to-read
materials. Beyond the Basics patient education pieces are longer, more sophisticated,
and more detailed. These articles are written at the 10 th to 12 th grade reading level and
are best for patients who want in-depth information and are comfortable with some
medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you
to print or e-mail these topics to your patients. (You can also locate patient education
articles on a variety of subjects by searching on “patient info” and the keyword(s) of
interest.)

 Basics topic (see "Patient information: Removing objects stuck in the ear (The
Basics)" )

SUMMARY — The table provides a differential diagnosis for otorrhea in children ( table
1 ). The approach to the evaluation of otorrhea in children is summarized in the
algorithms ( algorithm 1 and algorithm 2 and algorithm 3 ). Most children with otorrhea
have bacterial otitis externa or acute otitis media with perforation of the tympanic
membrane. 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). Children with persistent or recurrent otorrhea that does not respond easily to
appropriate treatment should be referred to an otolaryngologist.

REFERENCES
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3. Gliklich RE, Cunningham MJ, Eavey RD. The cause of aural polyps in children.
Arch Otolaryngol Head Neck Surg 1993; 119:669.
4. Harris KC, Conley SF, Kerschner JE. Foreign body granuloma of the external
auditory canal. Pediatrics 2004; 113:e371.
5. Persaud RA, Hajioff D, Thevasagayam MS, et al. Keratosis obturans and
external ear canal cholesteatoma: how and why we should distinguish between
these conditions. Clin Otolaryngol Allied Sci 2004; 29:577.
6. Shire JR, Donegan JO. Cholesteatoma of the external auditory canal and
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From : https://www.uptodate.com/contents/evaluation-of-otorrhea-ear-discharge-in-children