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Probability diagnosis

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Acute otitis media with perforation

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Chronic suppurative otitis media

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Furuncle (boil) of ear canal

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Infected otitis externa

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Reactive skin conditions e.g. eczema

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Liquified wax

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Serious disorders not to be missed

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Infection:

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  • Pseudomonas pyocyanea

  • Cholesteatoma

  • Herpes zoster oticus

  • Mastoiditis

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Cancer:

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  • Malignancy with discharge e.g. SCC

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Other:

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  • Cerebrospinal fluid otorrhoea (fractured temporal bone)

  • Necrotising otitis media

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Pitfalls (often missed)

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Foreign body with infection/liquidisation e.g. insects

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Trauma ± blood

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Rarities:

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  • Keratitis obliterans

  • Branchial or salivary fistula

  • Wegener’s granulomatosis

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Is the patient trying to tell me something?

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Factitious? Consider excessive manipulation of ear canal

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Key history

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  • Nature of discharge: acute or chronic, clear or bloody, offensive

  • Associated symptoms, esp. pain in ear or adjacent structures, fever, tinnitus, dizziness/vertigo, hearing loss

  • Use of ear drops and ear toilet

  • Previous history of ear problems and ear surgery

  • History of water sports, air travel, tropical residence or head injury

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Key examination

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Look for cause:

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  • Otoscopic view of ear and canal

  • Inspection of surrounding structures e.g. mastoid

  • Look for evidence of herpes zoster infection (sensory branch 7th cranial nerve)

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Key investigations

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First line:

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  • swab for M & C of ear discharge

  • simple bedside hearing tests

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Consider:

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  • X-ray mastoid

  • audiometry

  • wound swabs (if evidence infection)

  • duplex ultrasound

  • ankle brachial index

  • biopsy

  • KFTs

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Diagnostic tips

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Acute ear discharge is most likely due to otitis externa or perforated ear drum with otitis media.

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