How Should I Evaluate a Draining Ear?

Question

When a patient complains of ear drainage, how can I best identify the cause and treat it?

Judith S. Lynch, MS, MA, APRN-BC
Assistant Clinical Professor, Yale School of Nursing, Milford, Connecticut; Advanced Practice Nurse Practitioner, Naugatuck Valley ENT Associates, Waterbury, Connecticut

The Many Causes of Otorrhea

Several etiologies can cause otorrhea (drainage from the ear). Most of the time, otorrhea is caused by simple earwax or water that has entered the external ear canal (EAC) during swimming or a shower. This article discusses a few other common causes of otorrhea that the nurse practitioner might encounter in the primary care setting.

Acute Otitis Externa

Inflammation or infection of the EAC typically occurs in hot weather. The culprit is water, which causes a warm and moist environment that allows microbes to thrive.^[1] Acute otitis externa is classified as follows:

Acute diffuse: often seen in swimmers ("swimmer's ear");
Acute localized: associated with an infected hair follicle;
Fungal otitis externa;
Necrotizing or malignant: extending into deeper tissues and occurring in immunocompromised patients. This may result in osteomyelitis or cellulitis.^[1]
Chronic: lasts longer than 6 weeks; and
Eczematous: associated with atopic dermatitis or psoriasis.

Acute otitis externa is characterized by pruritus and otalgia (often severe), otorrhea (clear, yellow, and foul-smelling), sensation of aural fullness, tragal tenderness, diffuse EAC edema and erythema, and regional lymphadenopathy.

Elements of management for acute otitis externa include:

Dexamethasone 0.1% with ciprofloxacin 0.3% is the drug of choice. These combination drops inhibit bacterial DNA synthesis and growth, reduce canal edema, and relieve pain. Insert 4-5 drops twice daily for 7 days into the affected ear. Fungal infections may occur with longer courses^[1];
Strict water protection of the affected ear for 10-14 days;
Appropriate analgesia; and
Follow-up in 2 weeks.

Fungal Otitis Externa

The otorrhea associated with fungal otitis externa is typically whitish, with black fungal pads. Intense pruritus may be present. Fungal otitis externa often occurs after a prolonged course of antibiotic or steroid therapy for acute otitis externa. Treatment is the use of acetic acid solutions or a topical fungal agent (1% clotrimazole, 3-5 drops twice daily for 10-14 days). Water protection is mandatory.

Necrotizing or Malignant Otitis Externa

In addition to symptoms of acute otitis externa, the patient with necrotizing (malignant) otitis externa may have fever, dysphagia, facial weakness, and loss of voice. The cause is usually infection with Pseudomonas aeruginosa. A culture should always be obtained before treatment. CT or MRI of the head will confirm the diagnosis.

Treatment with appropriate antibiotic therapy may last several months. To reach infection deep in bone tissue, intravenous antibiotics may be necessary.^[2]

Chronic Eczematous Otitis Externa Due to Atopic Dermatitis or Psoriasis

Chronic otitis externa is caused by dry skin or psoriasis in the EAC, resulting in raw, draining ears with severe pruritus. This can be exacerbated by the use of cotton-tipped swabs. Bleeding of the ear canal is a cardinal sign. Rarely, cerumen is found in the EAC. Canal stenosis, if present, makes it difficult to examine the tympanic membrane.

Management of chronic otitis externa involves:

Fluocinolone acetonide 0.01% oil, a low- to medium-potency corticosteroid, 5 drops twice daily into the affected ear for 7 days. The patient should be taught the proper procedure for using ear drops and warned that because this is an oil, it may interfere with hearing for a short period;
After the first course of therapy, drops should be used only as needed when there is pruritus;
Constant water protection is necessary; and
Custom ear molds can be made for these patients.

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