Ear Discharge (Otorrhoea) Algorithm

1

Safety

Red Flags — Skull-Base, Intracranial & Traumatic Causes

Done

Most ear discharge is otitis externa or a perforated acute otitis media. The dangerous few are necrotising otitis externa, cholesteatoma, mastoiditis, intracranial spread and CSF leak. For ear pain without discharge see the Otalgia algorithm.

Necrotising (malignant) otitis externa Diabetes, immunosuppression or older age + severe, persistent pain (often worse at night), granulation tissue in the canal, discharge not settling with drops, or a cranial nerve palsy (facial) → Same-day ENT

Clear watery discharge after a head injury Possible CSF otorrhoea (basal skull fracture: haemotympanum, Battle's sign, panda eyes) → A&E for CT head within 1 hour (NICE NG232); 999 if GCS reduced. No drops, packing or syringing

Intracranial complication Severe headache, fever, drowsiness, neck stiffness, seizures, focal neurology or vertigo with neurological signs → 999

Mastoiditis Post-auricular swelling, tenderness or redness, pinna pushed forward, unwell child → Same-day hospital / ENT assessment

Facial weakness with ear discharge Cholesteatoma, necrotising otitis externa, Ramsay Hunt → Same-day ENT; eye protection if eye closure is incomplete

Button battery or sharp foreign body Or foreign body with bleeding, pain or suspected drum injury → Same-day ENT / emergency department

Sudden hearing loss or severe vertigo Sensorineural loss over 3 days or less within the last 30 days → Same-day ENT / emergency assessment (within 24 hours)

Persistent bloody discharge, canal mass or ulcer Especially in an older adult, or with facial pain or nodes → Urgent ENT referral (consider the head and neck suspected cancer pathway)

Necrotising otitis externa is a Pseudomonas osteomyelitis of the skull base. It looks like simple otitis externa at first; the clues are the host (diabetes, immunosuppression, older age), pain out of proportion and failure of topical treatment. Hospital teams arrange imaging, culture and prolonged antibiotics, and biopsy may be needed because malignancy can mimic it (ENT UK). Signs of basal skull fracture are a NICE NG232 indication for CT head within 1 hour.

2

Diagnose

History — Character, Duration and the Host

Done

Duration

Acute (days) versus persistent: discharge for 2 weeks or more through a perforation = chronic suppurative otitis media (CSOM)

Character

Purulent (bacterial), watery (eczema, early infection, CSF after trauma), cheesy or with black or white specks (fungal), scanty and foul-smelling (cholesteatoma, CSOM), bloodstained (trauma, granulation, polyp, tumour, AOM perforation)

Pain

Pain on moving the ear or jaw (otitis externa); severe pain that eased when the discharge started (AOM perforation); painless (CSOM, cholesteatoma); pain out of proportion (necrotising otitis externa)

Ear symptoms

Itch (otitis externa, fungal), hearing loss, tinnitus, vertigo, fullness

Preceding events

Cold or fever (AOM), swimming or water exposure, cotton buds, hearing aids or earbuds, recent drops, head injury, something put in the ear (children)

Background

Previous perforation, grommets or ear surgery; recurrent infections; eczema, psoriasis or seborrhoeic dermatitis; diabetes or immunosuppression; age

Treatment so far

Number of courses of drops — repeated failed courses point to fungal infection, contact dermatitis to drops, cholesteatoma or necrotising disease

Systemic and neuro

Fever, headache, facial weakness, double vision, swallowing or voice change (lower cranial nerves)

The classic description of cholesteatoma is painless, smelly, scanty discharge with hearing loss that keeps coming back despite drops. Neomycin and other topical agents can cause contact dermatitis that mimics a treatment failure.

3

Diagnose

Examination — Can You See the Drum?

Done

Outer ear

Pinna and tragal tenderness, swelling, cellulitis spreading beyond the canal, eczema, vesicles (Ramsay Hunt); pre- and post-auricular nodes; mastoid swelling and tenderness

Canal

Oedema, redness, debris, discharge colour; fungal hyphae or spores; granulation tissue (especially at the junction of bone and cartilage in diabetics), polyp, mass, foreign body

Drum

Visible and intact? Perforation (site and size), bulging or inflamed drum, grommet, attic (upper) retraction pocket or crust with white keratin (cholesteatoma). Document whether the drum could be seen

Hearing

Whisper test, tuning forks (Rinne, Weber) — conductive versus sensorineural

Nerves

Facial nerve (all branches, eye closure); other cranial nerves if necrotising otitis externa is suspected

General

Temperature, systemic state, neck stiffness; capillary glucose if diabetes is known or the otitis externa is severe or recurrent

After head injury

Haemotympanum, Battle's sign, periorbital bruising, clear fluid — do not insert instruments deeply

If the canal is too swollen or full of debris to see the drum, assume it may be perforated and choose non-ototoxic treatment. Granulation tissue in the canal of a diabetic patient with severe pain is necrotising otitis externa until proved otherwise.

4

Diagnose

Investigations — Only When They Change Management

Done

Ear swab

MC&S not needed for a first uncomplicated otitis externa. Take one for treatment failure, recurrent or chronic discharge, immunosuppression, suspected fungal infection, CSOM or suspected necrotising otitis externa (before systemic antibiotics where possible)

Glucose / HbA1c

Recurrent or severe otitis externa, or suspected necrotising disease — undiagnosed or poorly controlled diabetes

Audiology

Persistent hearing loss after the infection settles, CSOM, suspected cholesteatoma (often arranged by ENT)

Not in primary care

Testing fluid for CSF (beta-2 transferrin), CT or MRI, inflammatory markers for necrotising otitis externa — hospital teams arrange these

Swabs do not change initial management of straightforward otitis externa and should never delay treatment, but they guide therapy when first-line drops fail and identify fungal infection or resistant Pseudomonas.

5

Diagnose

Differential Diagnosis

Done

Otitis externa

Itch, pain on moving the pinna or tragus, swollen red canal with debris; swimming, cotton buds, skin disease. Usually bacterial (Pseudomonas, Staphylococcus aureus)

Fungal otitis externa

Itch, fluffy white or black debris, often after repeated antibiotic or steroid drops

AOM with perforation

Child or adult after a cold: severe pain and fever, then purulent discharge with relief of pain; pulsatile discharge through a small perforation

Grommet otorrhoea

Discharge through a ventilation tube, often after a cold or water exposure

CSOM

Painless, persistent or recurrent discharge for 2 weeks or more through a central perforation, with conductive hearing loss

Cholesteatoma

Scanty, foul, recurrent discharge; attic or posterior-superior retraction pocket or perforation with white keratin; hearing loss; may cause vertigo or facial weakness

Necrotising otitis externa

Older, diabetic or immunosuppressed; severe pain; granulation tissue; cranial nerve palsies late

Other

Foreign body (children, cotton wool), furunculosis, contact or seborrhoeic dermatitis, Ramsay Hunt syndrome, canal or middle-ear tumour, CSF leak after trauma or surgery, mastoiditis with a discharging sinus

Otitis externa and AOM can coexist, and discharge from a perforated drum can cause a secondary otitis externa. Cholesteatoma is locally destructive — it erodes ossicles, the facial nerve canal and the skull base, and can lead to meningitis or brain abscess — so persistent discharge needs ENT assessment rather than repeated drops.

6

Refer

Referral — Route and Urgency

Done

999

Suspected intracranial complication (meningitis, abscess, venous sinus thrombosis); head injury with reduced GCS

Same-day

Suspected necrotising otitis externa; suspected CSF otorrhoea after head injury (A&E, CT within 1 hour); mastoiditis; facial palsy with discharge; button battery or foreign body with drum injury; sudden sensorineural hearing loss; otitis externa with spreading cellulitis or a systemically unwell patient

Urgent ENT

Suspected cholesteatoma with vertigo, severe pain or neurological features; unexplained canal mass, ulcer or persistent bloody discharge

ENT / aural care clinic

Suspected cholesteatoma without complications; CSOM; canal too swollen or blocked for drops (microsuction, ear wick); otitis externa not settling after two courses; perforation not healed by 6 weeks; recurrent otitis externa

Primary care manage

Uncomplicated otitis externa; AOM with perforation in a well patient; grommet discharge per the local ENT pathway

Aural toilet (microsuction or dry mopping) is often what makes topical treatment work — drops cannot reach skin covered in debris. Most perforations from AOM heal within weeks; a perforation that persists needs ENT review for repair and to exclude cholesteatoma.

7

Treat

Management at This Consultation

Done

Otitis externa — mild

Acetic acid 2% ear spray

Usual adult dose: one spray three times daily for 7 days (product SPC; local). Analgesia (paracetamol or ibuprofen), keep the ear dry, remove the cause

Otitis externa — moderate or severe

Topical antibiotic ± steroid, 7 days

Drum intact: e.g. a neomycin–corticosteroid combination per the local formulary and SPC. Drum perforated, grommet present or drum not seen: avoid aminoglycosides — use a quinolone, e.g. ciprofloxacin ear drops; usual adult dose for ciprofloxacin 2 mg/mL single-dose drops: one container (0.25 mL) into the ear twice daily for 7 days (SPC). Ear wick or microsuction if the canal is very swollen. Oral antibiotics only for spreading cellulitis or systemic illness

Fungal otitis externa

Clotrimazole 1% solution

Usual adult dose: 2–3 times daily, continued for at least 14 days after symptoms resolve (NICE CKS; SPC). Stop antibiotic or steroid drops. Aural toilet if debris is heavy

AOM with perforation

Analgesia ± amoxicillin

Children (NICE NG91): with otorrhoea, consider no antibiotic, a back-up or an immediate antibiotic depending on severity, systemic features and follow-up; amoxicillin for 5–7 days if needed, dose by age per BNFC. Adults: usual adult dose amoxicillin 500 mg three times daily for 5–7 days if an antibiotic is needed (NICE CKS). No anaesthetic ear drops when perforated. Keep the ear dry

CSOM · grommet discharge

Aural toilet + quinolone drops

Dry mopping or microsuction and a topical quinolone per ENT advice or the local pathway; avoid aminoglycosides. Refer CSOM to ENT. Do not syringe

Foreign body

Remove only if easy and safe

One attempt with good light and a cooperative patient; otherwise ENT. Live insect: drown it with olive or mineral oil first. Button battery or drum injury → same-day ENT. Never syringe vegetable matter or a battery

Suspected NOESame-day ENT — do not manage with topical drops alone; check capillary glucose; swab before antibiotics if possible

Suspected CSF leakA&E — loosely cover the ear; nothing in the canal; advise not to blow the nose

Suspected cholesteatomaRefer ENT — drops may reduce discharge but do not treat the disease; no syringing

Next steps: see Otitis media and otitis externa

Aminoglycoside drops (neomycin, gentamicin, framycetin) are ototoxic if they reach the middle ear; ENT UK advises avoiding them with a perforation or patent grommet unless specifically advised. Quinolone ear drops are not ototoxic. Acetic acid and topical antibiotic–steroid drops have similar cure rates at 7 days, but acetic acid is less effective when treatment has to continue beyond a week.

8

Lifestyle

Ear Care & Prevention

Done

Keep it dry Cotton wool coated in petroleum jelly in the ear when showering or hair-washing; no swimming until settled (perforation: until healed).

Nothing in the ear No cotton buds, fingers or hairgrips; clean the outer ear only.

Using drops Lie with the affected ear up, put in the drops, press the tragus a few times and stay still for a few minutes.

Swimmers Well-fitting earplugs or a swim cap; dry the ears after swimming; acidifying drops before and after swimming may help recurrent otitis externa.

Skin and devices Treat eczema or seborrhoeic dermatitis; clean hearing-aid moulds and earbuds; remove hearing aids while the canal is inflamed.

Diabetes Good glucose control lowers the risk of severe and necrotising infection.

Water exposure and trauma to the canal skin are the main drivers of otitis externa; preventing them avoids recurrence and repeated courses of drops.

9

Safety

Follow-Up & Safety-Netting

Done

48–72 hours

AOM: return if not improving or worse; consider an antibiotic if none was given

7 days

Otitis externa not settling: re-examine, swab, consider fungal infection, contact dermatitis, aural toilet or a different drop; second failure → ENT

About 6 weeks

Check that a perforation has healed and hearing has recovered; persistent perforation, discharge or hearing loss → ENT

Safety-net 999

Severe headache, stiff neck, high fever with drowsiness or confusion, a fit, or new weakness or loss of balance with neurological symptoms

Safety-net same-day

Swelling, redness or pain behind the ear, the ear sticking out, facial weakness, sudden hearing loss or severe dizziness, severe pain that keeps you awake (especially with diabetes), or clear watery fluid after a head injury

Return

Discharge lasting more than 2 weeks, smelly discharge that keeps coming back, or hearing that does not recover

Recurrent courses of drops without re-examination are the commonest way to miss cholesteatoma and necrotising otitis externa. Document whether the drum was seen and intact, which drops were chosen and why.

👂 Ear Discharge (Otorrhoea)

Red Flags — Skull-Base, Intracranial & Traumatic Causes

History — Character, Duration and the Host

Examination — Can You See the Drum?

Investigations — Only When They Change Management

Differential Diagnosis

Referral — Route and Urgency

Management at This Consultation

Ear Care & Prevention

Follow-Up & Safety-Netting