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CASES MATERIA MEDICA GENERAL ARTICLES ABSTRACT MISCELLANEOUS Q & A

Ear Discharge
NATIONAL JOURNAL OF HOMOEOPATHY 1996 May / Jun Vol V No 3.
Milind Kirtane & Hetal Shah.

Otorrhoea is a common ENT complaint. Ear discharge may be attributed to various causes. Broadly it could be divided as arising from the external auditory canal, middle ear, inner ear and lastly due to causes outside the ear.

Characteristics of the discharge may give a clue to about its origin. The factors to be considered are colour of the discharge, quantity, odour and most importantly, associated symptoms such as pain, deafness, fever, headache, facial palsy, giddiness etc.

A sudden onset of ear discharge which is preceded by severe pain, may be due to a furuncle in the external auditory canal or due to perforation following an attack of acute otitis media.

External otitis may have various underlying pathologies, the commonest being fungal infection of the external auditory canal known as Otomycosis. it gives rise to itching as well as pain in the ear. It is more seasonal common in a humid climate, excessive sweating, swimming and a habit of cleaning the ear with ear buds often invite fungus. The color of discharge varies according to the type of infection eg-white or yellow with black discolouration like wet newspaper in Aspergillus niger infection, curd-like white in candidiasis and yellowish when there is infection with Aspergillus flavus. Presence of underlying diabetes mellitus can worsen this fungal infection. In the presence of uncontrolled diabetes this infection may spread to the base of the skull, resulting in osteomyelitis and subsequent malignant otitis external; malignant not histologically but by creeping spread along the skull base. Suppurative infection of the external auditory canal may result in formation of a furuncle. As there is a lack of connective tissue in the external, relieved only when it bursts open, resulting in ear discharge. The infection of the skin of the auditory canal may result in serous discharge if there is eczematous dermatitis. Viral infection of the external canal is usually seen in Herpes zoster infection where the rupture of vesicle is responsible for the serous discharge from the ear.

Following blockage of the eustachian tube, there is an infection in the middle ear cavity resulting in acute otitis media. To begin with, there is collection of exudate in the middle ear cavity, which becomes purulent if not treated in time and exits through a small perforation in the tympanic membrane. There is a pulsatile discharge and with it the pain and the ear block is relieved. Once the infection is treated, this perforation tends to heal without any residue. If the infection persists then it goes into chronic suppurative otitis media. The perforation may become even larger, which may ultimately require surgical correction.

In children, due to acute necrotising otitis media following perforation of the tympanic membrane which may not heal spontaneously. This perforation and a large perforation due to long standing acute chronic suppurative otitis media may go into secondary acquired cholesteatoma, thus turning a safe tubo-tympanic disease into an unsafe attico-antral disease which is discussed subsequently.

In attico-antral disease where there is a cholesteatoma, the ear discharge is usually scanty, foul smelling (due to infection by saprophytic organism) and occasionally blood stained. This has a tendency to erode bone and spread from the attic and antrum, to mastoid and even outside the confines of temporal bone resulting in intracranial complications. The osteomyelitis of the underlying bone results in the formation of granulation tissue which is responsible for blood stained discharge. the erosion of ossicular chain results in deafness. At times the infection may involve the bony canal of the facial nerve, resulting in facial palsy and even erode the bone of the semicircular canal resulting in a labyrinthine fistula.

One needs to examine the ear under the microscope to know the exact pathology. An audiogram may be required to know the type of hearing loss (whether conductive or sensory-neural), the level of hearing, the cochlear reserve, for medicolegal purpose and lastly as a record to compare with the post operative improvement. The x-ray of both the mastoids (Schullers view).

GENERAL SECTION

is taken to know the site, size and the extent of the disease. In addition, it gives an idea about the anatomical configuration of the mastoids.

The presence of cholesteatoma requires surgical treatment. Surgery aims at making the ear safe and dry and improving the hearing. For restoration of hearing, ossiculoplasty may be done at the same time or in two stages.

Another common cause of blood stained discharge is granuloma of the external auditory canal and granular myringitis. Repeated cleaning with ear buds is responsible for injury to the epithelial layer of tympanic membrane. Granulations form on the drum resulting in discharge. It gives a velvety appearance to the tympanic membrane. On any attempt to clean this discharge with buds, there is a further injury and thus a vicious cycle is established. Here, as there is no involvement of the middle ear or perforation of tympanic membrane, there is no deafness. Avoiding the use of buds helps. Rarely, blood stained discharge may be due to glomus jugularis or a vascular anomaly. Lastly blood stained discharge with a mass in the ear be due to malignancy of the external or middle ear.

A rare cause of Otorrhoea may be CSF leak which usually post traumatic where there is a clear watery discharge from the ear. To begin with, it may be blood stained due to trauma. The leak is through a dural tear, often in the tegmen or the roof of the external auditory meatus. Examination of this fluid for its sugar content confirms the diagnosis. This is a dangerous condition as there is the threat of recurrent meningitis due to ascending infection. This requires special imaging techniques viz. CT cisternography and / or MRI to know the exact site of leak for subsequent surgical closure. Lastly, there could be otorrhoea which is not related to ear disease. eg parotid fistula opening in the external auditory canal, in which saliva leaks in to the ear. The discharge is usually more at the time of meals. Even rupture of temporo-mandibular joint abscess or more commonly rupture of a pre-auricular or post-auricular suppurated lymph node may result in otorrhoea.

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