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Evaluation of otorrhea (ear discharge) in children

Evaluation of otorrhea (ear discharge) in children
Literature review current through: Jan 2024.
This topic last updated: Jul 07, 2023.

INTRODUCTION — The evaluation of otorrhea in children is reviewed here. The approach to ear pain is discussed separately. (See "Evaluation of earache in children".)

DEFINITION — Otorrhea means drainage of liquid from the ear. Otorrhea results from external ear canal pathology or middle ear disease with tympanic membrane perforation.

DIFFERENTIAL DIAGNOSIS — The table provides a list of etiologies for otorrhea in children (table 1). The history and physical examination will differentiate among most causes of otorrhea in children.

Life-threatening conditions — Otorrhea in the setting of a patient with trauma or immunocompromise may indicate a serious, life-threatening condition.

Traumatic cerebrospinal fluid otorrhea — Cerebral spinal fluid (CSF) otorrhea is a serious sign in the setting of head trauma. If any ear discharge is noted after serious head trauma, particularly clear or bloody discharge, the patient should undergo evaluation for CSF otorrhea caused by a basilar temporal skull fracture. (See "Skull fractures in children: Clinical manifestations, diagnosis, and management", section on 'Basilar skull fractures' and "Skull fractures in children: Clinical manifestations, diagnosis, and management", section on 'Basilar skull fracture'.)

Hemorrhagic otorrhea may also arise from middle ear trauma caused by a direct blow to the ear, auditory barotrauma, or intrusion of a foreign body into the external ear canal (picture 1). (See "Evaluation and management of middle ear trauma" and "Ear barotrauma".)

Infectious complications of acute otitis media — Because the mastoid air cells are connected to the distal end of the middle ear through a small canal or antrum, most episodes of acute otitis media (AOM) are associated with some inflammation of the mastoid. In rare cases, resolution of the mastoid infection does not occur, and acute mastoiditis develops with pus filling the air cells. The child with mastoiditis will have painful swelling behind the ear that typically pushes the pinna forward. (See "Acute mastoiditis in children: Clinical features and diagnosis".)

Other intratemporal complications that occur by contiguous spread of infection include petrositis (Gradenigo syndrome with sixth nerve palsy) and labyrinthitis.

Intracranial complications of AOM are particularly a concern in children who appear ill. These complications include meningitis, epidural abscess, brain abscess, lateral sinus thrombosis, cavernous sinus thrombosis, subdural empyema, and carotid artery thrombosis. Patients with these illnesses usually develop fever and, over time, a toxic appearance; a few may manifest cranial nerve deficits, especially cranial nerve VII (facial nerve) and less commonly, cranial nerve VI. (See "Acute otitis media in children: Epidemiology, microbiology, and complications", section on 'Intracranial complications'.)

Necrotizing otitis externa — Also called malignant external otitis, this is a complication of bacterial otitis externa. Infection of the skin gives way to deeper seeding of cartilage, tissue, and bone. As the infection advances, osteomyelitis of the base of the skull, temporomandibular joint osteomyelitis, brain abscess, and generalized bacterial sepsis can develop. Although most commonly seen in older adults and adults with diabetes mellitus, immunocompromised children (eg, cancer patients on chemotherapy or HIV-infected patients) are at risk.

Patients with malignant external otitis classically present with otorrhea and exquisite otalgia, which are not responsive to topical measures used to treat simple external otitis. The pain is generally more severe than that found in simple external otitis, although the two may be difficult to distinguish in their early stages. The pain in malignant external otitis tends to extend into the temporomandibular joint, resulting in pain with chewing.

On physical examination, purulent otorrhea is seen in more than half of cases, and ipsilateral lower motor neuron facial nerve palsy can be present as well. Granulation tissue may be visible in the inferior portion of the external auditory canal at the bone-cartilage junction (at the site of Santorini fissures). This finding may be absent in atypical patients (eg, HIV-infected patients and children). Early empiric antibiotic therapy and otolaryngology consultation are essential to good outcomes. (See "Malignant (necrotizing) external otitis".)

Neoplasm — Cancer is a rare cause of otorrhea but should be considered in patients with abnormal tissue growth in the ear canal or a lack of response to prolonged external otitis treatment. These patients warrant prompt referral to an ear, nose, and throat (ENT) specialist with pediatric expertise.

Ear canal cancer occurs far less frequently than auricular cancer, although the presentation and behavior are more sinister. In the early stages it is often indistinguishable from external otitis. In addition, rhabdomyosarcoma and neuroblastoma may manifest as auditory canal tumors in children. (See "External otitis: Pathogenesis, clinical features, and diagnosis", section on 'Carcinoma of the ear canal' and "Clinical presentation, diagnosis, and staging evaluation of neuroblastoma", section on 'Metastatic disease'.)

Common conditions — Otorrhea in children is often caused by one of several more benign diseases. Clinical findings after careful cleansing of debris will differentiate among most of these etiologies. (See 'External auditory canal cleaning' below.)

Bacterial otitis externa — Acute bacterial external otitis, often called "swimmer's ear," is an infectious inflammation of the external auditory canal. History often includes either water exposure or instrumentation with damage to the outer ear canal (such as cleaning with cotton swabs or finger scratching). Common symptoms include pain, pruritus, and hearing loss. Minor trauma to the canal's protective skin barrier and protective cerumen layer allows for bacterial overgrowth. Otitis externa is most commonly caused by Pseudomonas aeruginosa, although Staphylococcus aureus, Staphylococcus epidermidis, polymicrobial and anaerobic infections can occur. (See "Patient education: External otitis (including swimmer's ear) (Beyond the Basics)" and "External otitis: Pathogenesis, clinical features, and diagnosis", section on 'Diagnosis'.)

On physical examination, moderate to severe pain with minor tragus manipulation or pulling on the auricle is classic. An erythematous, edematous ear canal with cellular debris is seen. Since the middle ear is not necessarily involved in external otitis, there may not be any middle ear effusion or purulent otitis media. When visible, the tympanic membrane (TM) itself is typically erythematous or covered with debris. Often the membrane is difficult to see due to edematous narrowing of the canal. Otorrhea is purulent, white to yellow, and may dry to a crust.

Patients with severe forms of otitis externa may also have fever, regional lymphadenopathy, or erythema of the pinna. If the pinna is infected, very aggressive treatment may be necessary such as admission for intravenous antibiotics, topical soaks, and surgical debridement. It is important to make the distinction between a generalized cellulitis of the skin of the pinna and a more serious cartilage infection such as perichondritis or chondritis. This distinction may be made by inspecting the lobule, which has no cartilage. If the lobule is spared, but the rest of the pinna is erythematous, this suggests involvement of the pinna cartilage. (See "Pseudomonas aeruginosa infections of the eye, ear, urinary tract, gastrointestinal tract, and central nervous system", section on 'Perichondritis' and "External otitis: Pathogenesis, clinical features, and diagnosis", section on 'Malignant external otitis'.)

Foreign body — Ear foreign bodies (FBs) may cause otorrhea if they are long standing or consist of highly irritating substances. The history may or may not indicate their presence.

Typical FBs include:

Toys or small objects placed in the ear by toddlers, or placed into younger sibling's ears

Insects, although they are often so irritating that removal occurs before otorrhea develops

Food material, especially nuts with irritating oils that can cause a significant reaction

Button batteries (often used in small electronic devices such as hearing aids)

Expelled tympanostomy tube with granulation tissue and bloody otorrhea (see 'Tympanostomy tube drainage' below)

Button batteries require emergent removal because pressure necrosis and/or severe burns from residual electric current or leakage of caustic contents may rapidly lead to extensive damage to adjacent structures.

Otoscopy is diagnostic. However, cerumen buildup or otorrhea may obscure the object, and cleaning may be necessary before the FB can be seen. Most ear FBs that do not cause otorrhea can be removed using simple techniques in the outpatient setting without referral to an ENT specialist. However, complications do result from multiple manipulations, and an ENT consult should be called when in doubt or when necessary visualization and removal equipment are not available.

In patients with FBs that cause otorrhea, visualization and removal can be extremely difficult and must be done with care. Unless the clinician ensures visualization of the object and has the proper tools and setting (including the ability to restrain and possibly sedate the child), referral to an ENT specialist with audiometry is warranted. (See "Foreign bodies of the outer ear (pinna [auricle] and external auditory canal): Diagnosis and management" and "Procedural sedation in children: Approach".)

Acute otitis media — Occasionally, the tympanic membrane will rupture in the course of AOM. This is usually associated with ear pain and fever of relatively short duration, followed by pain relief associated with the onset of otorrhea. The drainage often has a clear or white appearance (picture 2 and picture 3). By the time the patient is seen, the perforation may have healed, but the drainage may continue for some time, especially if otitis externa has developed. (See 'Bacterial otitis externa' above.)

Often the perforation itself may not be visible on otoscopy because the otorrhea obscures visualization of the tympanic membrane (TM) or the perforation has rapidly resealed. When seen, the TM typically has abnormal appearance and lack of mobility on pneumatic otoscopy. If the perforation is of recent origin, it generally heals spontaneously once the infection resolves. (See "Acute otitis media in children: Epidemiology, microbiology, and complications", section on 'Tympanic membrane abnormalities' and "Acute otitis media in children: Treatment", section on 'Tympanic membrane perforation'.)

Chronic suppurative otitis media — Chronic suppurative otitis media (CSOM), or chronic otomastoiditis, is a perforation of the eardrum with chronic drainage from the middle ear cleft. This condition is more frequently seen in children who lack access to health care and, thus, do not have timely diagnosis and treatment of AOM. It should not be confused with longstanding otitis media with effusion (OME, or "serous" otitis media), or persistent AOM, both of which involve an intact tympanic membrane and no drainage. (See "Chronic suppurative otitis media (CSOM): Clinical features and diagnosis" and "Otitis media with effusion (serous otitis media) in children: Clinical features and diagnosis", section on 'Clinical features'.)

CSOM is often painless. On examination, a debris-filled canal is noted. The discharge is often white to yellow and mixed with soft cerumen. Pseudomonas aeruginosa and Staphylococcus aureus are common pathogens. Treatment typically consists of topical antibiotic ear drops, with topical quinolones being the best studied treatment choice. Parenteral antibiotic administration guided by culture of the ear discharge and/or tympanomastoidectomy may be necessary in refractory cases, though the evidence for superiority of systemic antibiotics over topical quinolone antibiotics is mixed and not convincing [1]. These refractory cases should be pursued in consultation with an ENT specialist.

Cerumen — Annoying to many parents/primary caregivers, but generally harmless, some children have thin cerumen that can present as ear drainage. 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" and 'External auditory canal cleaning' below.)

Tympanostomy tube drainage — 10 to 30 percent of children with tympanostomy tubes will have at least one episode of acute otorrhea while their tympanostomy tubes are in place, either immediately postoperatively or during an episode of AOM. The drainage is usually foul smelling, mucoid, and may be mixed with blood (picture 4). It is generally treated with antibiotic drops. Suction cleaning of the ear canal may be needed for drops to be effective. Rarely, systemic antibiotics or even mastoid surgery is needed if the drainage is persistent. (See "Tympanostomy tube otorrhea in children: Causes, prevention, and management", section on 'Treatment'.)

Other conditions — Less commonly, otorrhea may arise from the following conditions:

Contact dermatitis — Topical medications or cosmetics may cause local irritation and inflammation with ear drainage. A typical history reveals the offending agent being used, often for a pre-existing condition such as otitis externa or cerumen impaction. Pruritus, pain, and inflammation on examination accompany the otorrhea. Treatment consists of topical corticosteroids and avoidance of the allergen. (See "External otitis: Pathogenesis, clinical features, and diagnosis", section on 'Contact dermatitis'.)

Bullous myringitis — Often associated with respiratory symptoms or AOM, bullous myringitis describes serous liquid-filled blisters, or "bullae," on the tympanic membrane (picture 5). When the bullae rupture, thin bloody otorrhea may occur and pain is often relieved. The external ear canal is not typically involved. (See "Acute otitis media in children: Clinical manifestations and diagnosis", section on 'Bullous myringitis'.)

Granulation tissue — Granulation tissue can develop in a number of conditions and can be associated with otorrhea. As mentioned previously, this tissue can accumulate around a foreign body (such as a tympanostomy tube). It can also be seen in granulomatous disease (such as Langerhans cell histiocytosis), or in chronic inflammatory conditions (such as chronic otitis media). The rich vascular supply can also lead to leakage of lymphatic fluid [2]. (See "Clinical manifestations, pathologic features, and diagnosis of Langerhans cell histiocytosis".)

Polyps — Polyps in the external ear canal may occur in response to an inflammatory reaction or infection such as chronic otitis media, cholesteatoma, or retained foreign body (eg, expelled tympanostomy tube) [3,4]. Rarely, they may arise from a tumor (eg, Langerhans Cell Histiocytosis, teratoma, neoplasm). Polyps create 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 ENT specialist with pediatric expertise [5].

Otomycosis — Otomycosis is a fungal infection of the external auditory canal and a common reason for external otitis treatment failure. Patients with fungal external otitis most commonly report itching, a feeling that something is in the ear canal, discomfort, and discharge. Otorrhea is generally thick and purulent. Deep seated itching is the most troublesome symptom; pain is less intense than with bacterial otitis externa. Fungal organisms have a very characteristic appearance in the ear canal, especially under magnified vision (picture 6). The clinical manifestations and treatment of otomycosis are discussed in more detail separately. (See "External otitis: Pathogenesis, clinical features, and diagnosis", section on 'Otomycosis'.)

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.

Cholesteatoma — A cholesteatoma (sometimes called a keratoma) is an abnormal growth of squamous epithelium. These can occur in the middle ear and mastoid (middle ear cholesteatoma) (picture 7 and picture 8), or more rarely, in the ear canal itself (external ear canal cholesteatoma). It may progressively enlarge to surround and destroy the ossicles, resulting in conductive hearing loss. Hearing loss also may occur if the cholesteatoma obstructs the eustachian tube orifice, leading to middle ear effusion. Surgical therapy is required for most cholesteatomas. (See "Cholesteatoma in children".)

Keratosis obturans — Keratosis obturans is an accumulation of desquamated keratin in the external auditory meatus [6,7]. 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 generally 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. Operative care is typically not needed.

Spontaneous cerebral spinal fluid otorrhea — In addition to basilar skull fractures from head trauma, cerebrospinal fluid (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 otorrhea after the more common causes have already been excluded or in any child with more than one episode of meningitis. High resolution computed tomography (CT) with thin cuts through the temporal bone provides a noninvasive means of diagnosis [8].

EVALUATION

History — The following historical features should be sought in patients with otorrhea:

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

Fever – Fever suggests the presence of acute middle ear infection or necrotizing external otitis.

Pain – A painful ear makes benign chronic tympanic membrane perforation less likely. Pain with manipulation of the outer ear signals external canal inflammation (eg, otitis externa, foreign body).

Pruritus – Itching is a prominent feature of otitis externa (including otomycosis), allergic dermatitis, and ear foreign body.

Swimming history – Excessive water exposure is a common factor in the development of otitis externa. (See 'Bacterial otitis externa' above.)

Trauma – Otorrhea following significant head injury requires evaluation for cerebrospinal fluid leakage. Minor external trauma such as cleaning with cotton swabs or fingers may lead to bacterial otitis externa. (See 'Traumatic cerebrospinal fluid otorrhea' above and 'Bacterial otitis externa' above.)

Perforation – A perforation of the tympanic membrane (TM) may be traumatic, infectious, or surgical in origin (tubes). Any history of prior perforation of the tympanic membrane is important.

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.)

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

Physical examination — Examination of the ear requires:

Inspection of the auricle and surrounding area

Otoscopy of the external canal, tympanic membrane, and middle ear

In patients without obvious tympanic membrane perforation or bulging of the tympanic membrane with a clear diagnosis of acute otitis media, assessment of tympanic membrane function by pneumatic otoscopy (movie 1)

In children with otorrhea, the external auditory canal is often filled with debris and requires cleaning to allow proper visualization. (See "Cerumen", section on 'Cerumen removal'.)

External auditory canal cleaning — In most cases, no cleaning is necessary to make a diagnosis of otitis externa or otitis media with perforation. Not infrequently, however, careful removal of a small amount of debris enhances the view of the examiner, and this can be achieved using a cotton pledget wrapped tightly around a curette or a wick to soak up excess fluid.

Less commonly, careful cleaning through a standard otoscope head using a suction catheter or ear curette may be necessary to remove profuse, thick exudate that totally obscures the view of ear canal and tympanic membrane. Thorough cleaning is best done under direct visualization with use of either an otoscope with an operating head or an otologic microscope.

Some practitioners will use irrigation to remove cerumen, but this should only be done if a patient is known to have an intact tympanic membrane. Otherwise, irrigation of a draining ear is potentially dangerous and should not be performed.

Physical findings — Patient examination should focus on the following findings:

Head trauma – Any obvious head trauma or signs of basilar skull fracture (eg, raccoon eyes (picture 9), Battle sign (picture 10)) should raise suspicion for cerebrospinal fluid otorrhea. (See 'Traumatic cerebrospinal fluid otorrhea' above.)

Tragal motion tenderness – Pain with manipulation of the tragus or gentle traction on the auricle of the outer ear is a classic sign of bacterial otitis externa. However, some pain with manipulation may be present with any condition that generates inflammation of the external canal. (See 'Bacterial otitis externa' above.)

Foreign body – A foreign body (FB) found in the canal may be the source of a child's otorrhea and requires time to cause drainage. A child rarely may place something in the ear in an attempt to relieve symptoms from a pre-existing ear condition. Thus, after removal of the foreign body, careful otoscopic evaluation is important to exclude other coincidental disease or complications, such as tympanic membrane perforation. Care must be taken not to cause further injury during FB removal; any FB that is difficult to remove should be referred to an ENT specialist. (See 'Foreign body' above.)

Organic mass or polyp – Polypoid masses or granulomas most often arise in response to chronic otitis media, foreign bodies in the external ear canal, or cholesteatoma. Rarely, they may arise from a neoplastic process. (See 'Polyps' above and 'Neoplasm' above.)

Quality of discharge – Thin white debris-filled discharge is typical of bacterial otitis externa. Tympanic perforation generally leads to a mucous discharge as does contact dermatitis. Cerebral spinal fluid (CSF) otorrhea is a clear or thin bloody discharge that may be mistaken for more benign serous fluid. Purulent discharge can be from severe irritation, foreign body, middle ear infection, or severe external canal infections. Blood-tinged discharge is more likely caused by trauma, foreign body, granuloma, or carcinoma.

Inflammation – Inflammation of the tympanic membrane is indicative of middle ear pathology. Inflammation of the external canal can occur with many conditions, but it is less likely with isolated middle ear infections with or without TM perforations. An edematous, erythematous external canal with debris and a generally clear tympanic membrane is typical of bacterial otitis externa.

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'.)

Ancillary studies — History and physical examination are sufficient to diagnose and manage most causes of otorrhea in children.

Culture of ear drainage — Culture of the external ear canal in otorrhea is rarely helpful, as Pseudomonas species are commonly identified with or without local infection. It is also quite difficult to obtain samples from the middle ear that are not contaminated by external canal flora. In addition, culture rarely changes management decisions in children with otorrhea.

Indications for culture of ear drainage include:

Suspected necrotizing otitis externa

Otitis media with chronic drainage, where previous treatment has failed

When ear drainage culture is needed, an otolaryngology consultation is often necessary to obtain a proper specimen [9].

Testing for cerebrospinal fluid otorrhea — When in doubt about the presence of a CSF leak, it is best to obtain urgent neurosurgical consultation. (See "Skull fractures in children: Clinical manifestations, diagnosis, and management", section on 'Evaluation of CSF leakage'.)

Beta trace protein or beta-2-transferrin provide accurate testing for the presence of CSF but are not widely available.

Imaging — The clinician should consult with a pediatric ear, nose, and throat (ENT) specialist, neurosurgeon, or radiologist regarding preferred imaging to obtain when evaluating patients for the following diagnoses:

Basilar skull fracture with cerebrospinal fluid leakage (see "Skull fractures in children: Clinical manifestations, diagnosis, and management", section on 'Evaluation of CSF leakage')

Spontaneous cerebrospinal fluid leakage

Necrotizing otitis externa

Cholesteatoma

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.

Tissue biopsy — Patients with chronic external auditory masses may require tissue biopsy by an ENT specialist with pediatric expertise to establish a diagnosis. (See 'Neoplasm' above and 'Polyps' above.)

APPROACH — The initial evaluation should be focused on life-threatening causes of otorrhea (algorithm 1). In a stable, nontoxic patient, a systematic approach should start with a thorough history. Careful examination of the outer ear, external canal, and tympanic membrane should then reveal the diagnosis (algorithm 2 and algorithm 3).

Life-threatening conditions — Children with otorrhea and severe head trauma require evaluation and management of presumed basilar skull fracture with cerebrospinal fluid otorrhea (algorithm 1). (See 'Traumatic cerebrospinal fluid otorrhea' above.)

Children with fever and ill appearance warrant rapid assessment for infectious complications of acute otitis media (AOM), and necrotizing otitis externa. (See 'Life-threatening conditions' above.)

Chronic bloody otorrhea in children with an auditory external canal mass may herald the presence of a primary or metastatic neoplasm. (See 'Neoplasm' above.)

Nontoxic children — History and physical examination should be sufficient to establish a diagnosis for otorrhea in most children.

Noninflamed external canal — An external canal that appears pink, nonedematous, and noninflamed indicates likely tympanic membrane or middle ear pathology (algorithm 3). On examination of the tympanic membrane, bullous myringitis appears as multiple intact or ruptured blisters on the membrane itself, with possible middle ear inflammation behind. Granular myringitis can also be diagnosed on examination with visualization of the typical vascular, friable mass. A perforated tympanic membrane makes middle ear pathology the most likely source of the otorrhea.

Debris in AOM with perforation may make visualization of the tympanic membrane difficult, so other signs of otitis media such as fever and pain preceding the drainage may lead to the diagnosis of AOM with perforation. A noninflamed tympanic membrane with serous drainage through a perforation is likely chronic serous otitis media (CSOM), especially in an otherwise asymptomatic child. Although extremely rare, spontaneous cerebral spinal fluid (CSF) otorrhea has been described and should be considered when other more common causes of otorrhea have been excluded.

Inflamed external canal — An inflamed, edematous canal is typically associated with diseases external to the tympanic membrane (algorithm 2). After carefully clearing debris as needed, the examiner should check for a foreign body. A nonorganic foreign body can cause otorrhea when associated with concurrent irritation and inflammation. An organic appearing foreign body or growth in the ear suggests an inflammatory granuloma, polyp, otomycosis, carcinoma, or cholesteatoma. These masses each have their own characteristic appearance as described above.

An inflamed, edematous, debris-filled canal with no foreign body is typical of contact dermatitis and otitis externa. History of moisture exposure or minor trauma differentiates infectious otitis externa from contact dermatitis, which is associated with exposure of the ear to some topical medications, cosmetics, or plants. Otitis externa also tends to be more painful with outer ear manipulation, though contact dermatitis can become painful when severe as well. Pruritus is typical with both diagnoses. The clinician should carefully check for pinna and cartilaginous involvement of severe otitis externa.

SPECIALIST REFERRAL OR CONSULTATION — We recommend prompt consultation with a pediatric ear, nose, and throat (ENT) specialist for patients with otorrhea and the following conditions:

Cerebral spinal fluid (CSF) otorrhea (in addition to trauma and/or neurosurgical consultation if caused by trauma)

Mastoiditis or other infectious complications of acute otitis media

Auditory ear canal mass

Necrotizing otitis externa

Button battery foreign body

Congenital anomalies of the middle ear or ear canal

Immunodeficiency predisposing to severe infection

Referral to a pediatric ENT specialist is warranted for patients with:

Chronic otorrhea

Cholesteatoma

Otomycosis

First branchial cleft cyst

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 5th to 6th 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 10th to 12th 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

Definition – Otorrhea means drainage of liquid from the ear. Otorrhea results from external ear canal pathology or middle ear disease with tympanic membrane perforation. (See 'Definition' above.)

Differential diagnosis – The table provides a differential diagnosis for otorrhea in children (table 1). The history and physical examination will differentiate among most causes of otorrhea in children. (See 'Differential diagnosis' above.)

Common conditions – The majority of children with otorrhea have bacterial otitis externa or acute otitis media (AOM) with perforation of the tympanic membrane. (See 'Common conditions' above.)

Life-threatening conditions – Patients who are ill appearing or have otorrhea after head trauma require aggressive efforts to diagnose and treat potential life-threatening causes of otorrhea (basilar skull fracture, necrotizing otitis externa, infectious complications of AOM). (See 'Life-threatening conditions' above.)

Diagnostic approach – The diagnostic approach to the evaluation of otorrhea in children is summarized in the algorithms (algorithm 1 and algorithm 2 and algorithm 3). (See 'Approach' above.)

Specialist referral or consultation – Once a working diagnosis is established, prompt consultation with a pediatric ear, nose, and throat specialist is warranted for life-threatening conditions (eg, cerebral spinal fluid [CSF] otorrhea, mastoiditis or other infectious complications of AOM, necrotizing otitis externa, or neoplasm) and those that require biopsy for definitive diagnosis. (See 'Life-threatening conditions' above and 'Specialist referral or consultation' above.)

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