1. CHRONIC DISCHARGING EAR PRESENTED BY SALEH TAWFIQUE FRCS FRCSEd DLO SENIOR CONSULTANT HEAD EAR NOSE and THROAT DEPARTMENT AL AIN HOSPITAL

2. DISCHARGING EARS ( OTORRHEA) and Chronic Otitis Media
INTRODUCTION
What is meant by otorrhea in clinical practice in fact is an infective aural discharge.
Discharges from Ear can be CSF, blood, or pus and even can be wax.
CSF and blood usually follow trauma to temporal bone or skull base. It is rare in practice and usually follows RTA.
So in this lecture we concentrate on infective otorrhea.

3. DISCHARGING EARS ( OTORRHEA) and Chronic Otitis Media

4. DISCHARGING EARS ( OTORRHEA) and Chronic Otitis Media
TYPES OF INFECTIVE AURAL DISCHARGES:
Infective discharges from Ear can be
Mucopus
Frank purulent pus
Thick debris
Serosanguineous discharge if it contains blood.
CAUSES OF INFECTIVE OTORRHEA
* Otitis Externa
* Acute otitis media
* Chronic otitis media CSOM
Tubotympanic CSOM
Atticoantral CSOM
Clinically it is possible to tell, from the type of the discharge, whether the cause is :
Otitis Externa or Otitis Media.

5. DISCHARGING EARS ( OTORRHEA) and Chronic Otitis Media
Discharges due to otitis externa
Of different types depending on the causes of the infection whether it is allergic, bacterial or fungal otitis.
Allergic otitis externa causes itching, irritation in ear canal and the discharge here is clear watery and odorless.
Bacterial otitis externa give rise to thick yellow –green purulent pus mixed with debris.
Fungal otitis ( Otomycosis ) give rise to thick white yellow discharge
(Similar to wet blotted paper). This may contain black colored spores and hyphae.
All kinds of otitis externa the patient has also:
irritation in the ear with intense otalgia
tenderness on tragus on palpation.
And hearing loss which is minimal.
Send a swab for culture and sensitivity to confirm the type of the infection.

6. DISCHARGING EARS ( OTORRHEA) and Chronic Otitis Media
ACUTE OTITIS MEDIA
Patients usually after an upper Respiratory tract infection complain of intense throbbing pain in the ear, feeling "lock" and hearing loss.
This lasts for variable periods of time, from several minutes to few hours, depending on the virulence of the organisms.
If the condition is not treated it may lead to rupture of ear drum and profuse otorrhea.
Once the discharges come out the patient has no more otalgia.
Here the discharge is in the beginning is profuse, serosangioneous, pulsatile.
Gradually changes to mucopurulent and latter even frankly pus.
As the discharge comes from the middle ear, it contains a lot of Mucous.
(Compare to Otitis externa, no mucous is found in the discharge).
In otitis media the patients has more hearing loss and the ear is not tender on palpation. Unless there is some complication.

7. DISCHARGING EARS ( OTORRHEA) and Chronic Otitis Media
CHRONIC SUPPURATIVE OTITIS MEDIA (CSOM)
This is a chronic disease of insidious onset , causing irreversible changes and severe damage and destruction in the ears. Clinically presented by deafness and otorrhea.
Classification: CSOM is of 2 types Tubotympanic CSOM
Atticoantral CSOM with Cholesteatoma
Cholesteatoma is a sac lined by keratinized squmaous epithelium and contents keratin.( Epidermoid cyst) .

8. DISCHARGING EARS ( OTORRHEA) and Chronic Otitis Media
TUBOTYMPANIC CSOM

9. DISCHARGING EARS ( OTORRHEA) and Chronic Otitis Media
Tubotympanic CSOM
1. The disease process localized to the Eustachian tube and middle ear proper .
2. Usually it is complication of recurrent URTI
3. There is a central perforation in Pars Tensa of tympanic membrane.
4. The discharge is often long-standing and mucopus or purulent and may have foul smell. The discharge is profuse during exacerbations of URTI.
5. Hearing loss is variable depending on the extend of distraction .
6. Radiological exam. Rarely shows any bone
7. complications are rare and the disease is regarded safe.

10. DISCHARGING EARS ( OTORRHEA) and Chronic Otitis Media
Atticoantral CSOM

11. DISCHARGING EARS ( OTORRHEA) and Chronic Otitis Media
Atticoantral type of CSOM ,
1. The disease process localized to attic and mastoid antrum.
2. There is usually an attic perforation in Pars Flexida of tympanic membrane, with a retraction pocket which contains Cholesteatoma.
3. The cause is due to building of Cholesteatoma in the Middle Ear
4. The discharge here is scanty , full of white color debries and it has an embarrassing nature of smell , due to necrosis of bone and collagen connective tissue.
5. Hearing loss is nil or minimal in the beginning , but with time there will be severe hearing loss due to destructions of ossicles.
6. Radiological Exam. Usually reveal bone distraction.
7. This type of CSOM is unsafe and if not treated it leads to severe intracranial complications.

12. DISCHARGING EARS ( OTORRHEA) and Chronic Otitis Media

13. DISCHARGING EARS ( OTORRHEA) and Chronic Otitis Media

14. DISCHARGING EARS ( OTORRHEA) and Chronic Otitis Media
MANAGEMENT
The aim of treatment is to :
Control the infection and convert the active disease to non- active CSOM.
Prevent complications.
Restore the function of hearing by reconstruction of tympanic membrane and ossicles.
In cases of cholesteatoma to eradicate the active disease and prevent recurrence.

15. MANAGEMENT OF CSOM CSOM TUBOTYMPANIC ACTIVE INVESTIGATIONS,
ANTISEPTIC POWDER
REMOVAL GRANULATION
AURAL TOILET,
EAR DROPS ,
SWAB FOR C&S
PTA, CT MASTOID ETC
TREATMENT WITH ANTIBIOTICS
TISSUE AND POLYPS
NON ACTIVE
MYRINGOPLASTY OR
TYMPANOPLASTY

16. DISCHARGING EARS ( OTORRHEA) and Chronic Otitis Media
MANAGEMENT OF CSOM photo shows an aural polyp

17. MANAGEMENT OF CSOM CSOM TUBOTYMPANIC ACTIVE INVESTIGATIONS,
ANTISEPTIC POWDER
REMOVAL GRANULATION
AURAL TOILET,
EAR DROPS ,
SWAB FOR C&S
PTA, CT MASTOID ETC
TREATMENT WITH ANTIBIOTICS
TISSUE AND POLYPS
NON ACTIVE
MYRINGOPLASTY OR
TYMPANOPLASTY

18. MANAGEMENT OF CSOM HISTORY , EXAM UNDER MICROSCOPE
SWAB FOR C&S, PTA, CT MASTOID
CSOM
TUBOTYMPANIC TYPE
ATTICOANTRAL TYPE
ACTIVE
MASTOID EXPLORATION
SURGICAL TREATMENT
NON ACTIVE
MEDICAL TREATMENT
OBSERVATION

19. DISCHARGING EARS ( OTORRHEA) and Chronic Otitis Media
Possible complications of CSOM
Extracranial complications Intracranial complications
1. Mastoiditis Extradural abscess
2. Subperiosteal abscess and fistula 2. Subdural abscess
3.Bezold abscess Meningitis
4. Citelli abscess Brain abscess
5. Facial pulsy Lateral sinus Thrombosis
6. Labyrinthitis Otitic Hydrocephalus
7. Petrositis ( Gradenigo syndrome) 7. Encephalitis
otalgia, squint and otorrhea

20. DISCHARGING EARS ( OTORRHEA) and Chronic Otitis Media
CSF OTORRHEA.
After trauma , usually due to RTA , and fracture of skull bones , there might be a clear fluid discharge from the ear. The discharge increases during straining or coughing.
This may be due to tear in dura and leakage of CSF.
Send a sample to the lab for chemical analysis
BLOOD OTORRHEA
Usually follows trauma to the ear.
Very rarely may be due to a vascular lesion or vascular abnormality in the middle ear
Such as Glomus tumour , granulation tissue or vascular polyp.
In CSOM of a long –standing , bleeding from the ear is an ominous sign, indicating possibility of complications such as polyp formation or even malignant changes.

21. DISCHARGING EARS ( OTORRHEA) and Chronic Otitis Media
WAX
It is not rare in practice that patient attend clinic complaining of foul smell discharge , when after examination turns out to be due to normal wax.
Wax is excretion of apocrine glands in External ear canal. It is yellow , brown or even black in colour . Some time has an unpleasant smell. Other wise occur in every healthy person.

22. DISCHARGING EARS ( OTORRHEA) and Chronic Otitis Media
FINALY !
It is not rare in this country to get patients with profuse painless watery discharge. This may be due to T.B.
Here on examination of the Ear drum , the patient has multiple central perforation and with pale white granulation tissue in the middle ear

23. END OF PRESENTATION THANK U ANY QUESTION ?
AL MABZARA
AL KHAZRA