Otorrhea (ear discharge) in children: Causes and evaluation

INTRODUCTION — 

Otorrhea refers to drainage of fluid from the ear. It results from either external ear canal conditions (eg, otitis externa) or middle ear conditions (eg, acute or chronic otitis media) in conjunction with a nonintact tympanic membrane (ie, perforation or tympanostomy tube) (table 1).

The causes and evaluation of otorrhea in children are reviewed here. Related topics include:

●(See "Evaluation of earache in children".)

●(See "Acute otitis externa in children and adolescents".)

●(See "Acute otitis media in children: Clinical manifestations and diagnosis".)

●(See "Chronic suppurative otitis media (CSOM): Clinical features and diagnosis".)

●(See "Tympanostomy tube otorrhea in children: Causes, prevention, and management".)

CAUSES — 

Causes of otorrhea in children are summarized in the table (table 1). The history and physical examination will differentiate among most causes of otorrhea in children.

Common conditions — Otorrhea in children is most commonly caused by one of several benign conditions.

Acute otitis externa — Acute external otitis (AOE; also known as external otitis or swimmer's ear) refers to diffuse inflammation of the external auditory canal (EAC), which may also involve the pinna or tympanic membrane's ear. It is usually caused by bacterial infection, most commonly Pseudomonas aeruginosa, Staphylococcus aureus, or other gram-negative organisms. Risk factors for AOE include swimming or other water exposure, EAC trauma due to excessive cleaning or scratching of the ear canal, and devices that occlude the EAC (eg, ear buds or hearing aids).

Patients with AOE present with acute onset of otalgia, pruritus, or a feeling of fullness in the ear. If the ear canal is markedly swollen, the patient may report poor hearing in the affected ear. Fever is uncommon.

On examination, most patients have tenderness of the tragus (when pushed) and/or pinna (when pulled). The ear canal appears swollen, erythematous, and macerated with discharge present (picture 1).

The diagnosis of AOE is made clinically based upon the characteristic clinical presentation in conjunction with signs of EAC inflammation on examination (table 2).

AOE in children is discussed in detail separately. (See "Acute otitis externa in children and adolescents".)

Acute otitis media — Acute otitis media (AOM) occasionally is complicated by tympanic membrane (TM) perforation with associated otorrhea. The typical presentation is that of ear pain and fever for a relatively short duration, followed by pain relief that coincides with onset of otorrhea. The drainage often appears purulent (picture 2 and picture 3). (See "Acute otitis media in children: Clinical manifestations and diagnosis", section on 'Tympanic membrane findings'.)

Tympanostomy tube drainage — Otorrhea is common in children with tympanostomy tubes (TTs; also called "pressure-equalizing [PE] tubes" or "ventilation tubes") in place (picture 4). It can occur immediately after TT insertion from an existing AOM at the time of surgery, or later with subsequent middle ear infections.

TT otorrhea is discussed in greater detail separately. (See "Tympanostomy tube otorrhea in children: Causes, prevention, and management".)

Chronic suppurative otitis media — Chronic suppurative otitis media (CSOM) is characterized by chronic purulent middle ear drainage associated with TM perforation. It is a leading cause of hearing loss in resource-limited settings. It is less frequently seen in resource-abundant settings. The epidemiology, clinical features, diagnosis, and management of CSOM are reviewed separately. (See "Chronic suppurative otitis media (CSOM): Clinical features and diagnosis" and "Chronic suppurative otitis media (CSOM): Treatment, complications, and prevention".)

Foreign body — Foreign bodies of the EAC most frequently occur in children ≤6 years of age. Common foreign bodies in this setting include round beads, pebbles, small toys, food material, and insects. Ear drainage usually does not develop unless the object perforates the TM or the foreign body has been in the canal for some time. If the object has remained in the ear for a prolonged time, a granuloma may develop.

Visualization of the foreign body in the EAC on otoscopy confirms the diagnosis (picture 5 and picture 6). However, cerumen buildup or otorrhea may obscure the object, and cleaning may be necessary before the foreign body can be seen. (See 'Physical examination and otoscopy' below.)

In the absence of otorrhea, most ear foreign bodies can be removed using simple techniques in the outpatient setting without referral to an otolaryngologist. However, in patients with otorrhea, visualization and removal can be challenging and must be done with care. Unless the clinician ensures visualization of the object and has the proper tools and setting, referral to an otolaryngologist is warranted.

Foreign bodies in the ear are discussed in greater detail separately. (See "Foreign bodies of the outer ear (pinna [auricle] and external auditory canal): Diagnosis and management".)

Cerumen — Some children have thin cerumen that can present as ear drainage. This can be bothersome to patients and parents/ caregivers, but it is generally harmless. In general, cerumen is only a problem if it is impacted or if it precludes examination of the eardrum. In such cases, removal may be necessary, but precautions should be taken when instrumenting the ear canal. (See "Cerumen".)

Contact dermatitis — Contact dermatitis of the ear canal can occur due to an allergic reaction to ototopical drops (eg neomycin) (picture 7), cerumenolytics, perfumes, or contact with other materials adjacent to the ear canal (eg nickel in an earring). The inflammation from contact dermatis may cause ear drainage and pruritus. The history usually reveals the offending agent. Often the topical therapy in question is being used to treat cerumen impaction or an episode of AOE. Treatment consists of avoiding the irritant and use of a topical corticosteroid. (See "Allergic contact dermatitis in children".)

Traumatic tympanic membrane injury — Bloody ear discharge can occur following injury to the TM from a direct blow to the ear, auditory barotrauma, or perforation by an inserted foreign body (picture 8). These issues are discussed separately. (See "Evaluation and management of middle ear trauma" and "Ear barotrauma".)

Less common conditions

Cerebrospinal fluid otorrhea — Cranial cerebrospinal fluid (CSF) leaks occur when a dural tear or defect allows passage of CSF from the subarachnoid space into the extracranial space. Patients with CSF leaks through the ear generally have clear otorrhea, though the discharge may be bloody immediately after traumatic injury. CSF otorrhea can occur in the setting of serious head trauma or as a spontaneous event.

●Traumatic CSF leak – If ear discharge is noted after serious head trauma, the patient should undergo evaluation for a basilar temporal skull fracture. (See "Skull fractures in children: Clinical manifestations, diagnosis, and management", section on 'Basilar skull fractures'.)

●Spontaneous CSF leak – CSF otorrhea may also occur spontaneously through tegmen tympani defects in the floor of the temporal bone. These defects should be suspected in cases of persistent clear otorrhea without another identified cause. The diagnosis should also be suspected in a child with recurrent episodes of meningitis. High resolution computed tomography (CT) with thin cuts through the temporal bone can establish the diagnosis in most cases [1]. (See "Cranial cerebrospinal fluid leaks", section on 'Spontaneous CSF leaks'.)

Bullous myringitis — Bullous myringitis describes serous liquid-filled blisters, or "bullae," on the tympanic membrane (picture 9). These bullae are often associated with respiratory symptoms or AOM. When the bullae rupture, thin bloody otorrhea may occur, and pain is often relieved. The EAC is not typically involved. (See "Acute otitis media in children: Clinical manifestations and diagnosis", section on 'Bullous myringitis'.)

Mastoiditis — Mastoiditis is an uncommon complication of AOM, which may or may not be associated with otorrhea. Other characteristic features of acute mastoiditis include ear pain; postauricular tenderness, erythema, and swelling (picture 10); and protrusion of the auricle (picture 11). (See "Acute mastoiditis in children: Clinical features and diagnosis".)

Cholesteatoma — Cholesteatomas (sometimes called keratomas) are abnormal growths of squamous epithelium within the middle ear and mastoid (picture 12 and picture 13). They can be acquired or congenital. Most children with acquired cholesteatoma have a history of recurrent AOM and/or chronic middle ear effusions. Chronic ear drainage is the most common presenting symptom, though some patients are asymptomatic. Cholesteatomas progressively enlarge to surround and destroy the ossicles, resulting in conductive hearing loss. Additional details are provided separately (See "Cholesteatoma in children".)

Necrotizing otitis externa — Necrotizing external otitis (also called malignant otitis externa) is a rare severe invasive infection of the EAC leading to skull base osteomyelitis. The infection typically occurs in older adult patients with diabetes mellitus, but can occur in children, particularly children with underlying immunodeficiency. It is almost always caused by P. aeruginosa. Affected patients present with otorrhea and exquisite otalgia, which is out of proportion to examination findings and does not respond to topical treatments used for simple AOE. Necrotizing external otitis is discussed in detail separately. (See "Necrotizing (malignant) external otitis".)

Malignancy — Rarely, malignant conditions (eg acute myeloid leukemia, myeloid sarcoma) can present with external ear inflammation and otorrhea [2,3]. There are case reports of Langerhans cell histiocytosis presenting similar to AOE [4]. (See "Acute otitis externa in children and adolescents", section on 'Differential diagnosis' and "Acute myeloid leukemia: Children and adolescents" and "Clinical manifestations, pathologic features, and diagnosis of Langerhans cell histiocytosis".)

Otomycosis — Otomycosis is a fungal infection of the EAC most commonly caused by Candida and Aspergillus species (picture 14). It is more commonly seen in tropical or subtropical regions. It can also occur after repeated or prolonged use of ototopical antibiotic drops. Otomycosis typically presents as severe itching and crusting of the outer ear. Some affected patients may have otorrhea. (See "Acute otitis externa in adults: Treatment", section on 'Otomycosis'.)

Others

●Polyps – Polyps in the external ear canal may occur in response to an inflammatory reaction or infection such as CSOM, cholesteatoma, or retained foreign body (eg, expelled tympanostomy tube) [5,6]. Rarely, they may arise from a tumor (eg, Langerhans cell histiocytosis, teratoma, neoplasm). Polyps can produce bloody or serous otorrhea, generally when manipulated, similar to granulomas. Ear polyps may resolve rapidly with topical antibiotic and/or anti-inflammatory therapy. However, if drainage persists for more than two to three weeks, the child should be referred to an otolaryngologist with pediatric expertise [7].

●First branchial cleft cyst – The first branchial pouch arises in the pharynx and extends laterally and cephalad to contact the first branchial cleft, forming the eustachian tube. Rarely, congenitally anomalous first branchial cleft cysts may drain into the external ear canal. A mass in the periauricular region may suggest this diagnosis in the face of chronic drainage with a normal tympanic membrane.

●Keratosis obturans – Keratosis obturans is an accumulation of desquamated keratin in the external auditory meatus [8]. Unlike cholesteatoma, keratosis obturans is associated with an expanded ear canal as keratin is shed from the complete circumference of the canal and does not cause osteonecrosis. When compared with cholesteatoma, keratosis obturans is generally more acute and painful, produces less otorrhea, and occurs in younger patients. It can often be managed with removal of the keratin plug, antibiotic ear drops, and periodic follow-up to remove any reaccumulated debris [9]. Operative care is typically not needed.

EVALUATION — 

In most cases, the history and physical examination are sufficient to determine the most likely cause of otorrhea. Specific diagnostic testing is generally not necessary except in select circumstances as outlined below. (See 'Diagnostic testing (not necessary in most cases)' below.)

History — Relevant historical features include:

●Features of drainage – Onset, color, and consistency help distinguish among the etiologies of otorrhea. (See 'Physical examination and otoscopy' below.)

●Fever – Fever suggests the presence of acute middle ear infection; fever is not a characteristic feature of acute otitis externa (AOE).

●Pain – Pain with manipulation of the outer ear signals external canal inflammation (eg, AOE, foreign body).

●Pruritus – Itching is a prominent feature of AOE, allergic dermatitis, ear foreign body, and otomycosis.

●Swimming history – Significant water exposure is a common factor in the development of AOE. (See "Acute otitis externa in children and adolescents", section on 'Risk factors'.)

●History of trauma – Otorrhea following significant head trauma requires evaluation for cerebrospinal fluid leakage. Minor external trauma such as cleaning with cotton swabs or fingers may lead to AOE or tympanic membrane (TM) injury. (See 'Cerebrospinal fluid otorrhea' above and 'Acute otitis externa' above and 'Traumatic tympanic membrane injury' above.)

●History of tympanostomy tube (TT) placement or TM perforation – Otorrhea in patients with TTs in place or a history of TM perforation is often caused by middle ear conditions (eg, acute otitis media [AOM]).

●Medication usage – Topical medications, especially those containing neomycin, benzocaine, or propylene glycol can trigger a contact dermatitis of the external auditory canal. Other potential allergens include new cosmetics, ointments, and certain outdoor plants (eg, poison ivy). (See 'Contact dermatitis' above.)

●Duration and chronicity of ear drainage – A history of chronic or recurrent purulent ear drainage is suggestive of chronic suppurative otitis media (CSOM). (See "Chronic suppurative otitis media (CSOM): Clinical features and diagnosis".)

●Previous treatments – A draining ear that persists despite antibiotic treatment may indicate CSOM, otomycosis, or noninfectious causes of otorrhea.

Physical examination and otoscopy — Examination of the ear begins with visual inspection of the auricle, surrounding area, and external canal.

●Otoscopy and ear cleaning – Otoscopy is generally the appropriate next step to better visualize the external canal and TM. However, in children with otorrhea, the external auditory canal (EAC) is often filled with debris, and it may require cleaning for proper visualization. Carefully removing some of the debris enhances the view and can be achieved using a cotton pledget wrapped tightly around a curette or a wick to soak up excess fluid. Occasionally, a more thorough cleaning of the EAC using a suction catheter or ear curette may be necessary if there is a large buildup of purulent debris. This is best accomplished under direct visualization with either an otoscope or otomicroscope, provided the patient can tolerate the procedure. Some practitioners prefer to use irrigation to remove cerumen and debris from the EAC. However, this should only be done if the patient is known to have an intact TM. Otherwise, irrigation of a draining ear is potentially dangerous and should not be performed.

While otoscopic examination is a routine component of the evaluation of otorrhea in children, clinicians should be mindful that patients with moderate to severe AOE often experience extreme pain when the otoscope is placed in the ear canal. In most children with severe AOE, the diagnosis can be made with external examination alone, and otoscopic examination may not be necessary. (See "Acute otitis externa in children and adolescents", section on 'Diagnosis'.)

●Physical findings – Relevant findings on examination include:

•Inflammation of the EAC – An edematous, erythematous, and tender external canal is the hallmark of AOE. In severe AOE, the EAC may be extremely swollen such that little to no lumen is visible. (See "Acute otitis externa in children and adolescents", section on 'Clinical features'.)

•Tenderness of the tragus – Tenderness of the tragus (when pushed) and/or pinna (when pulled) suggests AOE. However, some pain with manipulation may be present with any condition that causes inflammation of the EAC. (See "Acute otitis externa in children and adolescents", section on 'Clinical features'.)

•Tympanic membrane – The tympanic membrane should be carefully inspected for signs of middle ear infection, such as injection, dullness, and bulging. Perforation, bullae, and evidence of trauma are additional important findings. (See "Evaluation and management of middle ear trauma", section on 'Findings of middle ear injury' and "Acute otitis media in children: Clinical manifestations and diagnosis", section on 'Otoscopic evaluation'.)

•Quality of discharge – Purulent discharge suggests an infectious etiology (eg, AOE, otitis media with nonintact TM). Traumatic TM perforation in the absence of infection generally produces a serous or mucous discharge. Cerebral spinal fluid (CSF) otorrhea is a clear or thin bloody discharge. Frankly bloody discharge is more likely caused by trauma or foreign body.

•Foreign body – A foreign body seen in the canal may be the source of a child's otorrhea, particularly if it has been there for some time. Rarely, a child may place something in the ear in an attempt to relieve symptoms from a separate ear condition. Thus, after removal of the foreign body, careful otoscopic evaluation is important to exclude other coincidental conditions or complications, such as TM perforation. Care must be taken not to cause further injury during removal of the foreign body. Any foreign body that is difficult to remove should be referred to an otolaryngologist. (See 'Foreign body' above.)

•Granuloma or polyp – Polypoid masses or granulomas most often arise in response to chronic otitis media, foreign bodies, or cholesteatoma. Rarely, they may arise from a neoplastic process. (See 'Chronic suppurative otitis media' above and 'Cholesteatoma' above and 'Foreign body' above and 'Malignancy' above.)

•Head trauma – Any obvious head trauma or signs of basilar skull fracture (eg, raccoon eyes (picture 15), Battle sign (picture 16)) should raise suspicion for cerebrospinal fluid otorrhea. (See 'Cerebrospinal fluid otorrhea' above and "Minor blunt head trauma in children (≥2 years): Clinical features and evaluation".)

Diagnostic testing (not necessary in most cases) — The history and physical examination are sufficient to diagnose most causes of otorrhea in children, and additional diagnostic testing is not necessary in most cases.

Culture of ear drainage — Cultures (obtained by swabbing the ear canal) are generally not helpful except in the following circumstances:

●Patients with AOE who have any of the following (these are uncommon) (see "Acute otitis externa in children and adolescents", section on 'Limited role for cultures'):

•Severe infection that is spreading to the surrounding tissues (eg, cellulitis of the pinna or parotid region)

•Immunodeficiency (eg, primary immunodeficiency, receiving immunosuppressive therapy after transplant, receiving chemotherapy)

•Recurrent or chronic otitis externa

•Persistent infection that did not respond to initial therapy

●Patients with suspected necrotizing otitis externa. (See "Necrotizing (malignant) external otitis", section on 'Ear canal drainage swab'.)

●Patients with chronic suppurative otitis media that persists despite first-line treatment. In this setting, cultures should be obtained through the TM perforation since cultures taken from the EAC may be contaminated by external canal flora. Otolaryngology consultation is often necessary to obtain a proper specimen [10]. (See "Chronic suppurative otitis media (CSOM): Treatment, complications, and prevention", section on 'Evaluation'.)

Testing for cerebrospinal fluid otorrhea — If a CSF leak is suspected, neurosurgical consultation should be obtained. (See "Skull fractures in children: Clinical manifestations, diagnosis, and management", section on 'Evaluation of CSF leakage'.)

A CSF leak may be diagnosed by detecting CSF proteins (beta-trace protein or beta-2-transferrin) from a collected sample of watery discharge, as discussed separately. (See "Cranial cerebrospinal fluid leaks", section on 'CSF-specific proteins'.)

Imaging — Imaging may be appropriate if any of the following diagnoses are suspected:

●CSF leakage (see "Skull fractures in children: Clinical manifestations, diagnosis, and management", section on 'Evaluation of CSF leakage' and "Cranial cerebrospinal fluid leaks", section on 'Neuroimaging')

●Necrotizing otitis externa (see "Necrotizing (malignant) external otitis", section on 'Determining extent of disease with imaging')

●Cholesteatoma (see "Cholesteatoma in children", section on 'Diagnosis')

●External auditory canal mass or chronic polyps

Specialized CT of the head with thin cuts through the temporal bone, middle ear, and otic capsule or magnetic resonance imaging (MRI) are potential options. The clinician should consult with appropriate specialist (eg, pediatric otolaryngologist, neurosurgeon, and/or radiologist) to guide the choice of imaging test.

Tissue biopsy — Rarely, patients with chronic external auditory masses may require tissue biopsy by an otolaryngologist to establish a diagnosis. (See 'Malignancy' above and 'Others' above.)

INFORMATION FOR PATIENTS — 

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Removing objects stuck in the ear (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Common causes of otorrhea in children – Otorrhea refers to drainage of fluid from the ear. It results from either external ear canal conditions (eg, otitis externa) or middle ear conditions (eg, acute or chronic otitis media) in conjunction with a nonintact tympanic membrane (TM) (table 1).

Common causes of otorrhea in children include (see 'Common conditions' above):

•Acute otitis externa (swimmer’s ear) (picture 1) (see "Acute otitis externa in children and adolescents")

•Acute otitis media complicated by TM perforation (picture 3) (see "Acute otitis media in children: Clinical manifestations and diagnosis", section on 'Tympanic membrane findings')

•Tympanostomy tube otorrhea (picture 4) (See "Tympanostomy tube otorrhea in children: Causes, prevention, and management".)

•Chronic suppurative otitis media (CSOM) (see "Chronic suppurative otitis media (CSOM): Clinical features and diagnosis")

•Foreign bodies (picture 5) (see "Foreign bodies of the outer ear (pinna [auricle] and external auditory canal): Diagnosis and management")

•Cerumen (see "Cerumen")

•Contact dermatitis of the ear canal (see 'Contact dermatitis' above)

•Traumatic injury of the TM (see "Evaluation and management of middle ear trauma" and "Ear barotrauma")

●Less common causes – Less common causes of otorrhea include:

•Cerebrospinal fluid leak (see "Skull fractures in children: Clinical manifestations, diagnosis, and management", section on 'Basilar skull fractures' and "Cranial cerebrospinal fluid leaks")

•Bullous myringitis (see "Acute otitis media in children: Clinical manifestations and diagnosis", section on 'Bullous myringitis')

•Mastoiditis (picture 10 and picture 11) (see "Acute mastoiditis in children: Clinical features and diagnosis")

•Cholesteatoma (picture 12 and picture 13) (see "Cholesteatoma in children")

•Necrotizing external otitis (see "Necrotizing (malignant) external otitis")

•Malignancy (see 'Malignancy' above)

•Otomycosis (fungal otitis externa) (See 'Otomycosis' above.)

•Polyps (see 'Others' above)

•First branchial cleft cyst (see 'Others' above)

•Keratosis obturans (see 'Others' above)

●Evaluation

•History and physical examination – In most cases, the history and physical examination are sufficient to determine the most likely cause of otorrhea. Examination of the ear begins with visual inspection of the auricle, surrounding area, and external canal. Otoscopy is generally the appropriate next step to better visualize the external canal and TM. However, in children with otorrhea, the external auditory canal (EAC) is often filled with debris, and it may require cleaning for proper visualization. (See 'History' above and 'Physical examination and otoscopy' above.)

Clinicians should be mindful that patients with moderate to severe otitis externa often experience extreme pain when the otoscope is placed in the ear canal. In most children with severe otitis externa, the diagnosis can be made with external examination alone, and otoscopic examination may not be necessary. (See "Acute otitis externa in children and adolescents", section on 'Diagnosis'.)

•Diagnostic testing – Most children with otorrhea do not require any additional testing since the cause is usually readily apparent from the history and examination. (See 'Diagnostic testing (not necessary in most cases)' above.)

-Limited role for cultures – Cultures (obtained by swabbing the ear canal) are not helpful in most cases but may be appropriate in select circumstances (eg, a child with refractory otitis externa or CSOM). (See 'Culture of ear drainage' above.)

-Limited role for imaging – Imaging may be appropriate in children with suspected CSF leak, cholesteatoma, necrotizing otitis externa, or EAC mass. The choice of imaging test should be guided by specialist consultation. (See 'Imaging' above.)