[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [ENT](https://durgical.com/en/ent/) › [Ear: approach to complaints](https://durgical.com/en/ent/areas/ear/) › Approach to ear discharge

# 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.

Updated Nov 5, 2026

## Key points

- Clean the canal before concluding: no eardrum seen, no diagnosis.
- Under IMCI (AIEPI), ear discharge for 14 days or more in a child is chronic otitis media.
- Tubotympanic chronic otitis media: central perforation, lower risk; atticoantral: retraction pocket or cholesteatoma, more complications.
- Scant, foul discharge with an attic retraction pocket or white flakes: cholesteatoma.
- Clear fluid after head injury: beta-2 transferrin to confirm a CSF leak.

## 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](https://durgical.com/en/conditions/otitis-externa/) | Purulent, painful | Swollen canal, intact eardrum |
| [Perforated acute otitis media](https://durgical.com/en/conditions/acute-otitis-media/) | Mucopurulent; pain eases when it perforates | Small perforation, under 14 days |
| [Chronic suppurative otitis media](https://durgical.com/en/conditions/otitis-media-with-effusion-and-chronic-suppurative-otitis-media/) | Mucopurulent, intermittent or persistent | Central perforation, conductive hearing loss |
| [Cholesteatoma](https://durgical.com/en/conditions/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.

[Add to my cards (4)](https://durgical.app/estudiar/?add=/en/ent/approach-to-ear-discharge/)

## Connections

## Related 4

- [Otoscopy: technique and the normal eardrum](https://durgical.com/en/ent/otoscopy-technique-and-the-normal-eardrum/)
- [Approach to hearing loss](https://durgical.com/en/ent/approach-to-hearing-loss/)
- [Otitis media in children: watchful waiting and ear tubes](https://durgical.com/en/ent/otitis-media-in-children-watchful-waiting-and-ear-tubes/)
- [Ear trauma: auricular haematoma, eardrum perforation and temporal bone fracture](https://durgical.com/en/ent/ear-trauma-auricular-haematoma-eardrum-perforation-and-temporal-bone-fracture/)

## Related conditions 3

- [Otitis media with effusion and chronic suppurative otitis media](https://durgical.com/en/conditions/otitis-media-with-effusion-and-chronic-suppurative-otitis-media/)
- [Cholesteatoma](https://durgical.com/en/conditions/cholesteatoma/)
- [Otitis externa](https://durgical.com/en/conditions/otitis-externa/)

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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](https://www.ncbi.nlm.nih.gov/books/NBK554592/) (StatPearls Publishing (NCBI Bookshelf), 2026); [Middle Ear Cholesteatoma](https://www.ncbi.nlm.nih.gov/books/NBK448108/) (StatPearls Publishing (NCBI Bookshelf), 2024); [Otitis Externa](https://www.ncbi.nlm.nih.gov/books/NBK556055/) (StatPearls Publishing (NCBI Bookshelf), 2023); [Cerebrospinal Fluid Leak](https://www.ncbi.nlm.nih.gov/books/NBK538157/) (StatPearls Publishing (NCBI Bookshelf), 2025); [Cuadro de procedimientos: Atención Integrada a las Enfermedades Prevalentes de la Infancia (AIEPI)](https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/VS/PP/cuadro-procedimientos-atencion-integrada-enfermedades-prevalentes-infancia.pdf) (Ministerio de Salud y Protección Social, Colombia, 2018).

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License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/ent/approach-to-ear-discharge/