Otorrhea is the discharge from the ear, which may be bloody (otorrhagia), purulent, serous, or serosanguineous. The onset, duration, consistency, color, and severity of discharge provide clues to the underlying pathology. Otorrhea may result from conditions affecting the external ear canal, middle ear, or surrounding structures, including infection, trauma, neoplasms, allergy, or systemic diseases. It may occur alone or with other symptoms, such as ear pain, hearing loss, tinnitus, or vertigo.

Pathophysiology

Otorrhea occurs when fluid, blood, pus, or serous secretions escape from the external auditory canal due to:

• Infection (bacterial, viral, or fungal) causing inflammation of the external canal, tympanic membrane, or middle ear.

• Trauma to the external ear or tympanic membrane.

• Neoplasms disrupting normal ear anatomy.

• Systemic conditions affecting vascular or connective tissues of the ear.

The type of discharge provides diagnostic clues:

• Clear, watery: may indicate cerebrospinal fluid (CSF) leak from basilar skull fracture.

• Purulent: suggests bacterial infection (otitis media, otitis externa).

• Bloody or serosanguineous: trauma, neoplasm, or acute myringitis.

History and Physical Examination

History:

• Ask when otorrhea began and how it was noticed (ear canal vs auricle).

• Characterize the discharge: color, consistency, odor, quantity, unilateral or bilateral, continuous or intermittent.

• Enquire about ear pain, tenderness, itching, tinnitus, vertigo, or hearing loss.

• Review recent infections, trauma, swimming habits, foreign body insertion, cancer history, dermatitis, or immunosuppressive therapy.

• Document medications that may predispose to infection or bleeding.

Physical Examination:

1. Inspect the external ear for erythema, edema, crusts, or polyps.

2. Palpate the tragus and mastoid area for tenderness.

3. Use an otoscope to examine the ear canal and tympanic membrane.

   • Note perforation, bulging, erythema, blebs, or absent light reflex.

4. Hearing assessment:

   • Whisper test

   • Tuning fork tests (Weber and Rinne)

5. Palpate neck and lymph nodes (preauricular, postauricular, parotid)

6. Assess cranial nerves VII, IX, X, XI for dysfunction

Medical causes

Special considerations

• Apply warm, moist compresses or heating pads to reduce pain and inflammation.

• Use cotton wicks for gentle cleaning or topical medication administration.

• Keep ear drops at room temperature to avoid vertigo.

• Ensure patients with hearing impairment understand instructions, using written materials if needed.

Patient counseling

• Demonstrate safe ear cleaning techniques.

• Advise ear protection during swimming.

• Educate on signs warranting immediate medical attention: persistent bleeding, severe pain, fever, dizziness, or worsening hearing loss.

Pediatric pointers

• Children’s ear canal lies horizontally; pull pinna downward and backward for examination.

• Restrain safely using parent lap positioning or prone positioning.

• Common causes in children: tympanic membrane perforation (post-otitis media) and foreign body insertion.

References

1. Berkowitz CD. Berkowitz’s Pediatrics: A Primary Care Approach. 4th ed. USA: American Academy of Pediatrics; 2012.

2. Buttaro TM, Tybulski J, Bailey PP, Sandberg-Cook J. Primary Care: A Collaborative Practice. St. Louis, MO: Mosby Elsevier; 2008.

3. Sommers MS, Brunner LS. Pocket Diseases. Philadelphia, PA: F.A. Davis; 2012.

4. Rosenfeld RM, Schwartz SR, Cannon CR, et al. Clinical practice guideline: Acute otitis externa. Otolaryngol Head Neck Surg. 2014;150:S1–S24.

5. Bluestone CD, Stool SE. Pediatric Otolaryngology. 5th ed. Philadelphia, PA: WB Saunders; 2014.