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Otorrhea—A fresh look at an old symptom

How do you know whether your patient’s ear infection is due to a bacterium or a fungus? What are the different methods of treating these painful conditions? What are the complications and sequelae? This comprehensive article has the answers.

Pamela Moyers Scott, MPAS, PA-C

The author is the owner of Physician Assistant Medical Services (P.A.M.S.) in Williamsburg, WVa, a past president of the AAPA, and president of the Society for the Preservation of PA History. She has indicated no relationships to disclose relating to the content of this article.

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Otorrhea is a common presenting complaint in the primary care setting.¹ Although most patients with otorrhea will have acute otitis externa (AOE), chronic suppurative otitis media (CSOM), tympanostomy tube otorrhea (TTO), or acute otitis media with perforation (AOM-P),² a comprehensive evaluation is essential to rule out more serious and potentially life-threatening etiologies. Table 1 outlines the differential diagnosis and provides key diagnostic clues in determining etiology.

Evaluation

A comprehensive history and physical examination are essential to establish the correct diagnosis. Evaluate the patient’s medical and surgical histories, as well as recent and current medications, for clues to underlying nonotic etiologies and immune system compromise. Table 2 lists additional information to obtain.

Physical examination During the examination, evaluate vital signs; the oral cavity, pharynx, nose, cervical lymph nodes, and areas overlying the mastoids and sinuses; the neck; and the temporomandibular joint. Additional examination may be necessary based on findings from the history and physical examination.

Of course, pay special attention to the ear. Meticulously inspect the auricle, the external auditory canal (EAC), and the surrounding skin for erythema, edema, trauma, or dermatoses. Palpate for tenderness and note any rubor. Move the pinna and tragus to evaluate for pain, and evaluate the discharge for color, consistency, odor, blood, and quantity.

Tympanic membrane (TM) Fully visualize and inspect the TM for perforations (including number, size, and location), color changes, signs of thickening and/or atrophy, prior scar formation, granulation, retraction, and vasculature pattern. Spontaneous TM rupture, including that caused by acute otitis media (AOM), is usually single and central in location. Perforated TMs due to failure to heal after tympanostomy tube (TT) removal or expulsion are single, generally occur in the anteroinferior (or occasionally the posteroinferior) quadrant, and exhibit evidence of surgical scarring peripherally. In addition, the patient will have a history of TT insertion.

The middle ear Evaluate the middle ear for an effusion or mass. Use a pneumatic otoscope to ascertain mobility. If the middle ear is obscured by the otorrhea, debris, a foreign body, or cerumen, remove the obscuring substance. This not only enables full visualization of the TM but also is part of the treatment process. Generally, the secretions can be mopped up with cotton-tipped applicators after fluffing the cotton, although low-pressure suction, utilizing a flexible number 5 or 7 Fr Frazier catheter, may also be used.³ Because most otorrhea is associated with some degree of EAC inflammation, the use of a curette is contraindicated, as it could cause further damage. Ear irrigation is also contraindicated because the pressure from flushing can create perforation in a weakened TM. The irrigating solution might travel into the middle ear cavity via this new perforation or a previous one, resulting in ossicular disruption and/or cochlear damage.

Removing the material If the material cannot be removed by mopping or suctioning or if it appears to be hard, flaky, and/or adherent to the EAC, then it is appropriate to instill a few drops of an otic antibiotic solution or hydrogen peroxide.³ Do this cautiously, however, to avoid inadvertently inserting the liquid into the middle ear cavity. Again, when the TM is not intact, the procedure can cause pain, vertigo, nausea, vomiting, ossicular disruption, and/or cochlear damage. Furthermore, polymyxin and aminoglycoside antibiotics are potentially ototoxic.⁴

If the secretions cannot be removed, attempts at removal are too painful, or the EAC is too edematous for the TM to be adequately visualized, then it is acceptable to insert a cotton ear wick with appropriate ototopical agents and then reevaluate the patient frequently.³ Alternatively, referral to an otorhinolaryngologist would also be appropriate.

Acute otitis externa

AOE is an infectious, inflammatory condition involving one or both of the EACs. It affects people of all ages, although it is rarely seen in children younger than 2 years. AOE occurs when the EAC’s normal defense mechanisms of cerumen production and migratory epithelial cells are disrupted, most frequently by increased EAC moisture and/or pH or trauma. These are the sorts of conditions that predispose the canal to an infection.³ Risk factors for AOE are listed in Table 3.

Pathogens The most common bacterial pathogens are Pseudomonas aeruginosa, which causes 40% to 60% of all cases, and Staphylococcus aureus, which causes approximately 15% to 30% of cases.⁵ Less frequently encountered pathogens include Escherichia coli, Proteus species, and Klebsiella species.⁶ The third most common cause, responsible for approximately 10% of all cases of AOE, is a fungus, usually Aspergillus species. The second most common fungal pathogen is Candida species.^3,5

Symptoms In addition to the otorrhea, AOE causes otalgia, which varies in intensity from mild discomfort to excruciating pain. The degree of pain often correlates with the extent of edema in the EAC. Other common symptoms include ear fullness, decreased hearing, pruritus, swelling, tenderness, and pain on mastication. If symptoms other than these are present, consider other etiologies for the otorrhea more carefully.

Physical examination The otorrhea itself will provide clues to the causative agent. Bacterial infections are generally associated with a white to cream-colored discharge that is moderate in amount and consistency, although it can be discolored and purulent.³ With fungal infections, the discharge is typically fluffy, more abundant, and white to off-white in color, although it can also be cream, black, gray, or aqua.³ The microspores on the hyphae are often visible during the otoscopic examination. Fungal infections are also less painful and more pruritic.⁵ However, if there is any doubt, use a potassium hydroxide preparation to aid in the diagnosis.

Additional physical findings include diffuse EAC erythema, edema, rubor and tenderness that might extend onto the auricle, and pain on movement of the pinna and tragus. The TM should be intact and normal in appearance. Preauricular lymphadenopathy may be present. The remainder of the physical examination should be relatively normal. If not, consider another diagnosis or a complication.

Complications These can include perforation of the TM; auricular cellulitis; external auditory canal stenosis and its associated sequelae; focal furuncle formation, especially in the lateral third of the canal; and necrotizing (or malignant) otitis externa. Necrotizing otitis externa is a potentially fatal condition that arises when the infection extends into the mastoid or temporal bones in immunocompromised patients.

Antibiotic treatment Suggested regimens for AOE include ofloxacin 0.3% twice a day; polymyxin B, neomycin, and hydrocortisone combination four times a day; and ciprofloxacin with hydrocortisone twice a day.⁷ Randomized controlled trials have revealed essentially equivalent treatment outcomes with all three options.^3,5,8 The twice-daily regimens may increase patient compliance.

When fluoroquinolones first became available, animal studies provoked concerns that articular cartilage deformities might develop in children. Since that time, systemic fluoroquinolones have been utilized in more than 1,000 children with cystic fibrosis without evidence of any joint damage.⁵ Furthermore, studies have demonstrated minimal, if any, systemic absorption from topically administered fluoroquinolones.⁵

It is unlikely that resistance will develop when fluoroquinolones are used as first-line agents because resistance to the fluoroquinolones occurs by single-step RNA mutation.⁵ This can happen only if the concentration of the antibiotic in the infected tissue falls below the minimum inhibitory concentration, which does not occur with ototopical utilization.⁵

Prevention In the past, acidifying drops, astringents, or alcohol after showering or swimming was recommended to prevent recurrences. Today, the drying method of choice is a hair dryer used on a low setting.³ The other agents are still appropriate for prophylaxis if they are not too irritating in patients who have canal deformities, who perspire profusely, or who wear hearing aids or ear plugs.³ A tight-fitting bathing cap has been shown to be a superior alternative to ear plugs in swimmers.³ Other preventive measures include avoiding the insertion of anything, including cotton-tipped swabs and fingernails, into the EAC; treating excessive cerumen production with ceruminolytic agents; avoiding ear irrigation; controlling underlying dermatoses; and attempting to keep soap and shampoo out of the EAC.

Acute otitis media with perforation

AOM-P can be either a complication of AOM or a condition that occurs when a person with prior TM perforation acquires AOM (see Figure 1). It is theorized that the middle ear space becomes infected either by the entrance of pathogens through the EAC via a TM perforation or by an upper respiratory tract infection (URTI). An estimated 21% to 50% of patients who have had TTs inserted develop AOM-P.⁵

Pathogens and symptoms Common bacterial pathogens include those seen in AOE, as well as Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.⁹ In addition to the otorrhea, patients may have ear pain, URTI symptoms, fever, and fatigue. The EAC may appear normal or may have mild inflammatory changes due to contact with the drainage in the dependent portions. The discharge is generally purulent and white to yellow or even green in color; it can be profuse. Pinna and tragus tenderness is minimal or absent. The TM tends to be erythematous, and the discharge is evident from the perforation. Nasal mucosa and pharyngeal findings are consistent with a URTI. Cervical adenopathy and fever may be present.

Complications and prevention Complications of AOM-P can include hearing loss, Bell’s palsy, labyrinthitis, mastoiditis, subperiosteal abscess, sternocleidomastoid muscle (Bezold’s) abscess, meningitis, brain and epidural abscesses, and dural venous thrombophlebitis.¹⁰ Preventive measures include keeping liquids from entering the middle ear cavity and avoiding the insertion of anything into the ear canal (including fingernails). The patient should avoid smoking and secondhand smoke, drink beverages only while fully upright, wash hands frequently, and disinfect shared items.

Chronic suppurative otitis media

There is no widely accepted definition of CSOM. In this article, it is defined as chronic or recurrent purulent otorrhea that has persisted for at least 6 weeks and that arises from a tympanic membrane perforation without a cholesteatoma. As with AOM-P, the middle ear space becomes infected either by the entrance of pathogens through the EAC via a TM perforation or by a URTI. Some consider CSOM to be a relapsing disease with recurrences of low-grade smoldering infections in the retrotympanic spaces, especially the mastoid air cells.¹¹ The majority of cases have a bacterial etiology, with the most common pathogens being P aeruginosa, S aureus, Staphylococcus epidermidis, Proteus species, Klebsiella species, and E coli. Prevotella and Porphyromonas anaerobes are also frequently recovered.⁹

Symptoms and complications The chief presenting symptom is generally otorrhea associated with aural fullness and decreased hearing. There are usually no systemic symptoms and little or no pain. Complications for CSOM are essentially the same as those for AOM-P.

Physical examination The TM is generally nonerythematous and perforated; it may reveal changes of chronic ear problems such as scarring, thickening, or atrophy. The discharge is essentially the same as that seen in AOM-P. The ear canal can appear relatively normal; however, it often has some mild inflammatory changes, especially in the dependent portions, because of the chronic exposure to the discharge. Pinna and tragus manipulation tenderness is minimal.

Antibiotic treatment Experts recommend ofloxacin or ciprofloxacin, with or without a corticosteroid, as the primary treatment choice; for alternatives, consider neomycin/polymyxin combination otic solution, gentamicin ophthalmic, or a boric acid/iodine powder mixture.⁹ Ofloxacin is the only one of these agents approved by the FDA for use in patients with perforated TMs. Controlled trials document its superiority over the other ototopicals and over some oral antibiotics with respect to overall cure rates, bacterial eradication, symptom relief, and adverse events, and many experts consider ofloxacin to be the preferred first-line agent.^3,5,8 Preventive measures for CSOM are same as those for AOM-P.

Tympanostomy tube otorrhea

TTO is drainage from the TT. Traditionally, it has been estimated to occur in 10% to 20% of patients with TTs; however, more recent studies have reported rates of 68% to 84%.⁴ If these later studies accurately reflect today’s incidence, TTO could become a very frequently encountered complaint in the primary care setting, since more than 2 million TTs are inserted annually.⁴

A wide variety of factors can lead to the development of TTO (see Table 4). Probably the most common cause is inflammation of the middle ear cavity and reflux of nasopharyngeal secretions via the eustachian tube into the middle ear cavity and out through the TT in association with a URTI.

Symptoms and physical examination Symptoms and findings on examination will vary depending on the etiology. Infectious etiologies tend to be accompanied by discolored discharge (ranging from white to cream, yellow, and green) that is more odorous, purulent, and viscous than that of other etiologies. Although a culture is necessary, empiric treatment should be started before results come back.

Antibiotic treatment Topical fluoroquinolones are considered first-line therapy.^4,5 This is probably because they have been found to be equally or more effective than other ototopical agents and they are not potentially ototoxic.⁸ Ofloxacin and ciprofloxacin appear to be equivalent, although ofloxacin does have the benefit of being approved by the FDA for use when the middle ear cavity is exposed. Furthermore, there have been isolated case reports of TT obstruction caused by ciprofloxacin.¹² This may be because ciprofloxacin is more viscous than the other ototopical agents and has the tendency to form concretions that can precipitate in the lumen of the tube.¹²

General issues in treatment

Cleansing The cornerstone of treatment for all four of these conditions is gentle and frequent cleansing. After initially being performed by the health care provider (HCP), cleansing can usually be accomplished at home by the patient, parent, spouse, or other caregiver using fluffed-out tips on cotton ear swabs. In rare cases, the patient may have to return to the HCP for repeat suctioning or swabbing. If an ear wick is necessary, the patient needs to be reevaluated at least every 2 to 5 days until symptoms improve and the wick is no longer needed.³

Pain control This is essential, and the choice of drug depends on the severity of the pain. Mild pain can be alleviated with a topical benzocaine solution, provided the TM is intact, or with OTC analgesics such as acetaminophen, ibuprofen, naproxen, or aspirin. More severe pain requires prescription analgesics, including narcotics.

Antibiotic drops When a bacterial etiology is being considered, topical antibiotic drops are indicated (see Table 5). Ointments should never be used.⁷

A recent meta-analysis failed to reveal any randomized clinical trials comparing treatment outcomes in subjects given oral antibiotics versus either placebo or otic antibiotic drops.⁸ Systemic antibiotics should be considered only if the patient is younger than 2 years, exhibits early signs of complications, appears toxic, is immunocompromised (including having diabetes), or is unresponsive to topical treatment.^3-5 Despite the recommendations not to use antibiotic drops alone in patients younger than 2 years, fluoroquinolones (with or without an added corticosteroid) are approved by the FDA for use in some of these conditions, starting at 6 or 12 months of age.^13-15

Corticosteroids The decision to add a topical corticosteroid preparation to the treatment regimen must be individualized. Randomized clinical trials reveal mixed results regarding their benefit.^3,8 Additionally, corticosteroids can act as a topical sensitizer.³ They appear most useful when there is marked edema or an underlying dermatologic condition.⁶

Antifungals No topical otic antifungals have been FDA approved for treating otomycosis. The following solutions may be used: 3% boric acid and 70% isopropyl alcohol, 2% acetic acid, or 2% acetic acid and 70% isopropyl alcohol. These should be used only if the TM is intact.⁹ Oral antifungals should be given if the TM is not intact or if the infection is severe or unresponsive to topical preparations. An otorhinolaryngologic consult is indicated before initiating oral antifungal treatment.

Conclusion

Perhaps the best summary statement on the currently recommended treatment of otorrhea is from an article by Myer entitled, “The evolution of ototopical therapy: from cumin to quinolones”:

A radical change has occurred in the management of otorrhea over the past decade. Multiple studies have supported the efficacy of topical quinolones in the management of acute otitis media, acute otitis externa, and CSOM. For the first time, otolaryngologists have a scientific foundation on which to base our treatment protocols for these conditions. We no longer must rely solely on our clinical experience and prejudices. The quinolone drops have a superior safety profile and a broad antimicrobial spectrum, their overall cost is lower than the alternatives, and their convenient dosing schedule is tolerated well by most patients. When one takes all these factors into consideration, it becomes clear that topical quinolone therapy, with or without a steroid additive, is the treatment of choice for otorrhea in patients with a tympanic membrane perforation or ventilating tube. The development of ototopical medications has followed along the lines of Darwinian evolution, and the quinolone drops have clearly demonstrated the concept of “survival of the fittest.”¹⁶

REFERENCES

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7. Gilbert DN, Moellering RC Jr, Eliopoulos GM, Sande MA. Clinical approach to initial choice of antimicrobial therapy. In: Gilbert DN, Moellering RC Jr, Eliopoulos GM, Sande MA, eds. The Sanford Guide to Antimicrobial Therapy, 2004. 34th ed. Hyde Park, Vt: Antimicrobial Therapy, Inc; 2004:2-45.

8. Hajioff D. Otitis externa. Clin Evid. 2005;14:669-675.

9. Microbiology and drug selections for treatment of infections in the ear, nose, throat, head, and neck. In: Fairbanks DN. Pocket Guide to Antimicrobial Therapy in Otolaryngology–Head and Neck Surgery. 11th ed. Alexandria, Va: American Academy of Otolaryngology—Head & Neck Surgery Foundation; 2003:26-45.

10. Durand M, Joseph M. Infections of the upper respiratory tract. In: Braunwald E, Fauci AS, Kasper DL, et al, eds. Harrison’s Principles of Internal Medicine. 15th ed. New York, NY: McGraw-Hill; 2001:187-193.

11. Deitmer T. Topical and systemic treatment for chronic suppurative otitis media. Ear Nose Throat J. 2002;81(8 suppl 1):16-17.

12. Bassim MK, Drake AF. Tympanostomy tube obstruction related to ototopical drug therapy. Ear Nose Throat J. 2005;84(7):416-417.

13. Floxin Otic and Floxin Otic Singles prescribing information. Available at: http://www.floxinotic.com/prescribing_info.htm. Accessed July 20, 2006.

14. Ciprodex Otic prescribing information. 2006. Available at: http://www.ciprodex.com/professional/default.asp. Accessed July 20, 2006.

15. Cipro HC Otic suspension prescribing information. Available at: http://www.ciprohc.com/general/how-to-use-cipro.asp. Accessed July 20, 2006.

16. Myer CM 3rd. The evolution of ototopical therapy: from cumin to quinolones. Ear Nose Throat J. 2004;83(1 suppl):9-11.