Reasoning GP · Algorithm · 1-page summary
Ear discharge (otorrhoea)
For: adults and children with ear discharge in primary care. Not for: ear pain without discharge (otalgia algorithm); head injury assessment itself (NICE NG232).
Core rule: document whether you saw the drum. If you cannot, assume it may be perforated. Discharge that keeps coming back needs re-examination, not another course of drops.
0Stop — call 999 now
- Intracranial complication — severe headache, fever with drowsiness, neck stiffness, seizure, focal neurology → 999
- Head injury with reduced GCS → 999. Clear fluid after a head injury → A&E for CT within 1 hour; nothing in the ear.
1Triage by host and drum
| Finding | Action |
|---|---|
| Diabetic or older | Severe pain, granulation, not settling → Same-day ENT |
| Drum intact | Otitis externa → acetic acid or antibiotic ± steroid drops |
| Drum perforated or unseen | No aminoglycosides; quinolone drops |
| Discharge 2 weeks or more | CSOM or cholesteatoma → ENT |
2Screen
- Mastoid swelling, pinna pushed forward → Same-day
- Facial weakness with discharge → Same-day ENT
- Button battery or drum injury → Same-day ENT
- Sudden hearing loss or severe vertigo → Same-day (within 24 hours)
- Canal mass, ulcer, persistent bloody discharge → Urgent ENT
3Assess
☐ Tragal tenderness, nodes, mastoid ☐ Canal: debris, fungus, granulation, foreign body ☐ Drum seen and intact? ☐ Hearing, facial nerve ☐ Glucose if diabetic or recurrent ☐ Swab only if failure, recurrent, fungal or high risk
Do not: syringe a perforated ear, a battery or vegetable matter.
4Classify
- Otitis externa — itch, pain moving the pinna, swollen canal.
- Fungal — fluffy white or black debris after repeated drops.
- AOM with perforation — pain then discharge with relief.
- CSOM — painless discharge 2 weeks or more, central perforation.
- Cholesteatoma — scanty, foul, recurrent; attic retraction → ENT.
- Uncertain — drum not seen: treat as perforated; review in 7 days.
5Treat today — doses per SPC, BNF/BNFC and formulary
- Mild OE: acetic acid 2% one spray three times daily for 7 days.
- Moderate OE: antibiotic ± steroid drops 7 days; perforation → ciprofloxacin drops.
- Fungal: clotrimazole 1% solution; stop antibiotic drops.
- AOM perforation: analgesia; amoxicillin 5–7 days if needed (NG91).
6Refer routinely
- ENT or aural care: CSOM, uncomplicated cholesteatoma, canal too swollen for drops, failure after two courses.
- Perforation not healed by 6 weeks; recurrent otitis externa.
7Never reassure by
- "Just otitis externa" in a diabetic with severe pain.
- Drops that reduced the discharge of a cholesteatoma.
- Clear fluid after a head injury.
- A drum you did not actually see.
- Repeat prescriptions without re-examination.
8Safety-net — say it, then document it
999 “Call 999 for a severe headache, stiff neck, high fever with drowsiness or confusion, or a fit.” Same day “Contact us the same day for swelling behind the ear, facial weakness, sudden hearing loss or dizziness, severe pain that keeps you awake, or clear fluid after a head injury.”
Return if discharge lasts more than 2 weeks or hearing does not recover.
✓Safe to manage in primary care only if — all five, documented
No block 0–2 feature
Drum status documented
Diabetes or immunosuppression considered
Drops chosen for drum status; review booked
Safety-net and ear care advice given
Summary of the full Reasoning GP ear discharge algorithm, which holds the detail and evidence. Sources: NICE CKS Otitis externa and Otitis media; NICE NG91; NICE NG232; ENT UK. Clinical reference — check doses in the current SPC and your local formulary.