Otorrhea

What is Otorrhea?

Otorrhea is a medical term that refers to any discharge coming from the ear. It’s not a condition itself but a symptom of an underlying issue with the ear. This can range from a watery fluid to pus or even blood. While the presence of ear discharge might seem alarming, it's important to understand that it can have many different causes and treatments. For a comprehensive overview of various ear conditions, you can read more about when our ears get sick.

In most cases, otorrhea indicates an underlying condition that needs medical attention. It can be a sign of an infection, injury, or other ear-related issues. Knowing more about otorrhea can help you take appropriate steps for treatment and care.

Types of Otorrhea and What They Mean

The type of discharge coming from the ear can provide important clues about the cause:

• Yellow, White or Green Discharge: This is the most common form of discharge. This often indicates an ear infection like otitis externa (swimmer’s ear), and can be bacterial or from fungus overgrowth. It can also be caused by otitis media (middle ear infection) if it ends up rupturing the eardrum to release the pus (infectious liquid). 
  
  
• Serous (thin but clear or slightly yellow): This type of discharge is often clear and may indicate skin irritation or a mild infection. This type is common in people with skin conditions (eczema, psoriasis) and-or in individuals who excessively manipulate their ears (scratching, Q-tip, ear irrigations, etc.). The skin becomes irritated and will weep.
  
  
• Bloody Discharge: This could be due to trauma, such as a scratch in the ear canal, or more severe issues like a tumor or injury to the eardrum.
  
  
• Thick and Foul-Smelling Discharge: This is commonly associated with chronic external ear infections or cholesteatomas, a condition where a skin cyst builds up in the middle ear. The foul smell is very typical for the presence of the bacteria Pseudomonas.
  
  
• Earwax Mixed with Fluid: Sometimes, discharge can simply be earwax that’s been softened by water or an ear infection. This is not serious and is self-resolving.
  
  
• Clear and watery Discharge: This might result from a cerebrospinal fluid (CSF) leakage after a head injury, which is rare but serious. CSF is the fluid that surrounds and protects the brain. Normally, it is contained inside the skull by the dura mater (a thick lining that envelops the brain). In cases of trauma, there can be a tear in that membrane and the fluid can leak out of the ear when there is a perforation of the eardrum, or if a healthcare professional attempts to drain it. Sometimes, CSF leaks in the ear can occur even without trauma if there is a defect in the base of the skull in which the bone is missing and there is a communication between the brain compartment and the ear. You can read more about CSF leaks in this article (coming soon).
  
  

Common Causes of Otorrhea

Several conditions can lead to otorrhea, including:

• Middle ear infections (otitis media): This is a very common cause, especially in children. When pressure builds up behind the eardrum, it can rupture, allowing fluid to drain out. Produces a thick, white or green discharge that is often accompanied by blood.
  
  
• Outer ear infections (otitis externa): Also a very common cause. It is known as swimmer's ear, and this condition causes drainage, ear pain and often hearing loss. The outer ear becomes very sensitive even to mild manipulation. Otitis externa is most commonly caused by bacteria (most commmon is called Pseudomonas) but can also be caused by fungus (most common would be Aspergillus or Candida). This very commonly occurs after repeated water exposure (typically swimming). The type of discharge can help determine which kind of infection it is. In a fungal infection, the doctor can sometimes see the black spores of the fungus, or sometimes the discharge is of "wet tissue paper" consistency. Fungal infection can also sometimes follow a prolonged use of antibiotics (by mouth or more typically in drops). It's quite common to see after patients self-medicate with over-the-counter polysporin drops during weeks! 
  
  
• Eardrum Perforation: A hole or tear in the eardrum can result from infections, Eustachian tube dysfunction, trauma, or sudden pressure changes, among other things.
  
  
• Tympanostomy Tube (ear tube): A tube through an eardrum is called "transtympanic" or "tympanostomy" tube. When you have a cold or a runny nose, it's normal that the ear tube will leak: it's doing its job! Essentially, it prevents the mucus buildup in the middle ear that would eventually lead to an infection (otitis). However, a tympanostomy tube can cause long-term ear discharge because it gives bacteria an easy way to get into the middle ear from the outer ear. This constant exposure to germs, along with changes in the ear caused by the tube, can lead to ongoing swelling and fluid leaking. Also, the tube might interfere with the ear's natural cleaning, letting dirt and bacteria build up, which makes the ear discharge problem worse. Lastly, the tube itself can become contaminated with bacteria (creating what we call a biofilm) leading to chronic low-grade infection. The tube is usually replaced in those situations if medical treatment fails.
  
  
• Trauma: Injury to the ear canal, such as from inserting cotton swabs or earbuds, can cause discharge.
  
  
• Cholesteatoma: This is an abnormal growth of skin cells in the middle ear that get infected and will lead to chronic discharge and damage. It is more common in individuals who had trouble with ear infections all their childhood, as it is a sign of Eustachian tube dysfunction. This problem needs surgical intervention. You can read more on this topic here.
  
  
• Foreign Objects: Something stuck in the ear, common in children, can cause irritation and discharge.
  
  
• Skull Fractures: Rarely, a fracture can lead to cerebrospinal fluid leaking into the ear canal (see above).
  
  
• Skin Conditions: Very common cause of drainage. Eczema or dermatitis affecting the ear canal can also result in otorrhea. 
  
  

How to Take an Ear Specimen for Culture

An ear specimen is not always required to treat ear discharge. However, if you have persistent or unusual ear discharge, your doctor might need to identify the exact cause by testing the fluid. Here’s how it’s done:

1. A sterile swab is carefully inserted into the ear canal to collect a sample of the discharge. This is done under the microscope or under direct visualisation to make sure we do not contaminate the swab with skin bacteria and to make sure we do not damage surrounding structures.
2. The sample is sent to a lab to identify any bacteria, fungi, or other microorganisms causing the infection. It usually takes 1-2 days to obtain culture results for bacteria, and usually 2-5 days for fungus.
3. Based on the results, your doctor can recommend the most effective treatment.
   
   

Effective Treatments and Water Protection for Otorrhea

Treating otorrhea depends on its underlying cause. Here are some common treatments:

Topical Antibiotics

Topical (applied as drops) antibiotics are commonly used to treat infections causing otorrhea. It's important to note that certain topical antibiotics should be used with caution, especially if there's a possibility of a perforated eardrum as they can be toxic and damaging to the inner ear. Always consult with a healthcare provider before using any ear drops. Some options include:

1. Non-Ototoxic Antibiotics:

   • Ciprofloxacin and Ofloxacin: These are safe, even if the eardrum is perforated.

   • Dexamethasone with antibiotics: Combines anti-inflammatory effects with antibacterial action. Also safe to use.

2. Ototoxic Antibiotics:

• • Neomycin/Polymyxin B combinations: While effective, these can harm the inner ear (ototoxic) if the eardrum is ruptured, potentially causing hearing loss. 
    
    
  • Gentamicin and Tobramycin: Highly effective but ototoxic, used cautiously and typically for short durations. It is important to make sure there is no eardrum perforation prior to using these drops.
     

Oral Antibiotics

In cases of severe infection, oral antibiotics may be prescribed.

Antifungal Medications

If a fungal infection is identified, antifungal drops or cream may be necessary. In Canada, one of the most common anti-fungal drop we prescribe is Locacorten-Vioform. Exercise caution, as many antifungal drops are ototoxic, posing a risk if used with a perforated eardrum. In cases where the eardrum is perforated and a fungal infection is present, I carefully apply antifungal cream using a cotton applicator under direct microscopic observation to ensure the medication does not enter the eardrum perforation and harm the inner ear. One or two applications are usually necessary for a full recovery (usually once a week).

Cleaning the Ear

In cases of otorrhea and otitis, it is important to clean the ear debris and remove the discharge (whether it's pus, mucus, blood or other) to make way for the antibiotic drops to get to the bottom of the ear canal. Ear debridement is an essential component of treating otorrhea.

Water protection

It is crucial during an ear infection to prevent water from penetrating in the ear to avoid further complications and to allow appropriate healing. Here are some tips (for more information on water-related ear conditions, check out our article on swimmer's ear: symptoms, treatments, and prevention)

1. Keep Ears Dry: Avoid swimming and use earplugs while showering.

2. Use Cotton Balls: Place a cotton ball in the outer ear to keep it dry, but do not insert it into the ear canal.

3. Avoid Ear Irrigation: Do not irrigate or flush the ears unless advised by a healthcare professional.