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Probability diagnosis

Acute otitis media with perforation

Chronic suppurative otitis media

Furuncle (boil) of ear canal

Infected otitis externa

Reactive skin conditions e.g. eczema

Liquified wax

Serious disorders not to be missed


  • Pseudomonas pyocyanea

  • Cholesteatoma

  • Herpes zoster oticus

  • Mastoiditis


  • Malignancy with discharge e.g. SCC


  • Cerebrospinal fluid otorrhoea (fractured temporal bone)

  • Necrotising otitis media

Pitfalls (often missed)

Foreign body with infection/liquidisation e.g. insects

Trauma ± blood


  • Keratitis obliterans

  • Branchial or salivary fistula

  • Wegener’s granulomatosis

Is the patient trying to tell me something?

Factitious? Consider excessive manipulation of ear canal

Key history

  • 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

Key examination

Look for cause:

  • 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)

Key investigations

First line:

  • swab for M & C of ear discharge

  • simple bedside hearing tests


  • X-ray mastoid

  • audiometry

  • wound swabs (if evidence infection)

  • duplex ultrasound

  • ankle brachial index

  • biopsy

  • KFTs

Diagnostic tips

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

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