What is Otorrhea?
Otorrhea basically means any kind of flow or discharge from the ear. According to the World Health Organization, an inflammation of the middle ear at a stage of a disease pertaining to the ear, where there is a chronic infection of the middle ear leading to a perforated tympanic membrane and subsequently a discharge from the middle ear is actually termed as chronic otorrhea. This stage of the middle ear cleft is termed as chronic Suppurative Otis Media (CSOM). If CSOM persists for more than 6 to 12 weeks then it is termed as chronic otorrhea. The discharge may be purulent, serous or serosanguineous and may contain cerebrospinal fluid. It is a common pediatric ailment but rarely seen in adults and complications of the same can be serious.
Leakage of cerebrospinal fluid from the ear structures is termed as CSF otorrhea, which is a dangerous to life condition in which an otolaryngologist is immediately contacted for intervention. A skull fracture, infection, tumors, congenital abnormalities and a surgical shock can lead to this condition. The most prominent reason of CSF leakage is due to a miscommunication or a fistulous connection betwixt the tympanomastoid cavity and subarachnoid space, which takes place when a person is at risk for meningitis. A cerebellopontine angle surgery might lead to a traumatic injury or neoplastic ear disease, both can lead to otorrhea CSF. If the above mentioned conditions are not present and still there is CSF seepage, then it clearly indicates a case of rhinorrhea (runny nose). In rhinorrhea the fluid flows from the Eustachian tube, the one which links pharynx to the middle ear.
Purulent Otorrhea or purulent Otis media is defined by a thin hazy or cloudy outpouring. The sub-epithelial space or the epithelial layer is filled with poly-morpho-nuclear leukocytes and bears an edematous appearance and is discarded. Most possibly a bacterial contagion of the Eustachian tube is the cause of purulent Otis media but a systemic infection can even cause it. The inflammatory cells can lead to tympanogenic meningitis by entering the internal auditory canal.
Otorrhea with Tubes
Otorrhea with tubes or Tympanostomy tube otorrhea (TTO) usually occurs after a tube was inserted in the middle ear from an existing infection present in the ear canal. It is also referred as post-tympanostomy tube otorrhea (PTTO) and is characterized by a discharge from an existing tympanostomy tube. If TTO occurs within 2 weeks of the placement of the tube, then it is referred as early-onset TTO. While, if TTO occurs after 2 weeks of the tube placement then it is called as late-onset TTO. It has been found that at least 10 to 20 percent of children undergoing Tympansotomy tube placement, develop TTO early within two weeks.
Some of the basic otorrhea causes are as follows;
- Over exposure to water due to swimming, swimmer’s ear or Otis externa
- Presence of an object in the ear, as commonly seen in children.
- A serious blow to the ear in case of a head injury may lead to seepage of cerebrospinal fluid from the brain due to basilar skull fracture
- Damage to the ear tissue due to a difference in pressure inside and outside of the eardrum. This is called Barotrauma.
- Head colds
- Presence of acute Otis media along with perforation.
- Presence of Chronic Otis media with either Cholesteatoma or perforated ear drum, or both.
- External ear canal dermatitis.
Different causes of otorrhea will determine the consistency and color of the discharge.
- Unsteadiness or Vertigo.
- Pain and discomfort in one or both the ears.
- Partial or slight loss of hearing.
- There will be a sensation of stuffiness present in the ear.
- Constant pressure will be felt inside the ear as felt when under the water.
- Bleeding from the nose.
First of all upon the assessment of the presence of otorrhea, the GP will use a special suction device in order to clean the discharge from the affected ear. After this only he will try to locate the precise sight from which the drainage is taking place. Topical antibiotics will be prescribed and it is mandatory not to wet your ear and avoid swimming until the course of the treatment. One should not try to wash the ear with water to clean the discharge as it will pressurize the eardrum and lead to its perforation.
The use of antibiotics should be restrained until a spinal tap confirms symptoms of meningitis. A trans-canal approach is also recommended to treat CSF otorrhea. On the other hand a trans-mastoid approach is preferred in case of a spontaneous discharge as the precise location of the leakage is not known.
Otorrhea Differential Diagnosis
For an otorrhea differential diagnosis, the discharge is cultured for a careful examination. The type of antibiotic to be used will be determined by a gram stain of the discharge.
- Purulent otorrhea is the acute and chronic suppurative otitis media with or without perforation of the eardrum.
- A basilar skull fracture can cause CFS otorrhea.
- Non-purulent otorrhea is the Swimmer’s ear, foreign body, CFS fluid leakage,otitis externa.
- Bloody otorrhea: trauma to external canal or middle ear due to some head injury, barotrauma or foreign body invasion.