Approach to ear discharge
- Approach to a complaint
The look of the discharge, how long it has lasted and the state of the eardrum point to the cause; clear fluid after trauma may be CSF.
What it is
Otorrhoea is discharge from the ear canal. It can arise in the canal (otitis externa) or in the middle ear through a perforation (perforated acute otitis media, chronic suppurative otitis media, cholesteatoma). Clear, watery fluid after head injury or surgery may be cerebrospinal fluid. Three facts guide you: what the discharge looks like, how long it has been there and what the eardrum looks like once the canal is cleaned. Persistent foul-smelling discharge with hearing loss suggests cholesteatoma, which is always referred.
Key questions in the history
- How long has it lasted, and is it continuous or intermittent?
- What is it like: purulent, mucoid, foul, clear or bloody?
- Is it painful? Hearing loss, vertigo or facial weakness?
- Previous otitis, ear surgery, head injury or swimming?
- Diabetes or immunosuppression?
- Fever, headache or drowsiness?
Causes and classification
- From the canal: bacterial or fungal otitis externa, foreign body, furuncle.
- From the middle ear through a perforation: perforated acute otitis media (recent) or chronic suppurative otitis media (persistent or recurrent).
- Tubotympanic chronic otitis media (central perforation) versus atticoantral (retraction pocket, cholesteatoma).
- Clear and watery after trauma or surgery: cerebrospinal fluid leak.
- Bloody: trauma, bullous myringitis, granulation tissue or, rarely, a tumour.
Step-by-step approach
- Pin down duration, appearance, smell, pain and history (otitis, trauma, surgery, swimming, instrumentation).
- Clean the canal (suction or dry mopping) to see the eardrum.
- Inflamed canal with an intact eardrum: otitis externa.
- Perforation with mucopurulent discharge: perforated acute otitis media if recent; chronic if it lasts 14 days or more.
- Scant, foul discharge with a retraction pocket, white flakes or granulation: suspect cholesteatoma.
- Look for complications: vertigo, facial palsy, pain behind the ear, headache or high fever.
- Clear fluid after trauma or surgery: collect a sample for beta-2 transferrin.
Differential diagnosis of ear discharge
| Cause | Discharge | Otoscopy and clues |
|---|---|---|
| Otitis externa | Purulent, painful | Swollen canal, intact eardrum |
| Perforated acute otitis media | Mucopurulent; pain eases when it perforates | Small perforation, under 14 days |
| Chronic suppurative otitis media | Mucopurulent, intermittent or persistent | Central perforation, conductive hearing loss |
| Cholesteatoma | Scant and foul | Attic retraction pocket, white flakes, granulation |
| CSF leak | Clear and watery | Trauma or surgery; positive beta-2 transferrin |
| Trauma or bullous myringitis | Bloody | Laceration or blisters on the eardrum |
Red flags
- Persistent foul discharge with hearing loss: cholesteatoma.
- Vertigo or facial palsy: complication in the middle ear or temporal bone.
- Fever, headache, neck stiffness or drowsiness: intracranial complication.
- Swelling behind the ear: mastoiditis.
- Clear fluid after head injury: CSF leak with a risk of meningitis.
- A diabetic with severe pain and granulation: necrotising otitis externa.
Next step / Initial management
- First management: clean and dry the canal (wicking) and quinolone ear drops; IMCI (AIEPI) uses ciprofloxacin ear drops for chronic otitis media in children.
- If the eardrum is perforated, avoid aminoglycoside drops because of ototoxicity.
- Discharge for 14 days or more, recurrent or foul: routine ENT referral with audiometry; cholesteatoma is treated with surgery.
- Mastoiditis, facial palsy, vertigo or meningeal signs: urgent same-day referral to hospital.
- Suspected CSF leak: beta-2 transferrin, temporal bone CT and urgent referral to ENT or neurosurgery.
Test yourself
Think of the answer, then tap the question to see it.
A 6-year-old has had mucopurulent discharge from the right ear for 3 weeks with a central perforation. How does IMCI (AIEPI) classify it and what do you do?
Chronic otitis media (discharge for 14 days or more): dry wicking, quinolone ear drops and ENT referral.
An adult has years of scant foul ear discharge, hearing loss and an attic retraction pocket with white flakes. What do you suspect?
Acquired cholesteatoma: ENT referral for CT and surgery, because it erodes bone and causes complications.
After a head injury, clear fluid drains from the ear. Which test confirms it is CSF?
Beta-2 transferrin in the fluid, which is highly sensitive and specific.
Why are aminoglycoside drops avoided when the eardrum is perforated?
Because they can reach the inner ear and be ototoxic; topical quinolones are preferred.
Connections
Educational content; it does not replace a medical assessment and is not a clinical instruction. For a real case, follow current guidelines and specialist advice.
Sources: Chronic Suppurative Otitis (StatPearls Publishing (NCBI Bookshelf), 2026); Middle Ear Cholesteatoma (StatPearls Publishing (NCBI Bookshelf), 2024); Otitis Externa (StatPearls Publishing (NCBI Bookshelf), 2023); Cerebrospinal Fluid Leak (StatPearls Publishing (NCBI Bookshelf), 2025); Cuadro de procedimientos: Atención Integrada a las Enfermedades Prevalentes de la Infancia (AIEPI) (Ministerio de Salud y Protección Social, Colombia, 2018).
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Representative model, for educational purposes only.