Ear and nasal discharge

Surgery > Ear, nose & throat

Differential Diagnosis Schema 🧠

Ear Discharge (Otorrhea)

Acute otitis media with perforation: Sudden onset ear pain followed by purulent discharge, often after a respiratory infection
Chronic suppurative otitis media: Persistent ear discharge, hearing loss, history of recurrent ear infections
Otitis externa: Painful ear with discharge, often associated with swimming or trauma (e.g., Q-tip use)
Cholesteatoma: Foul-smelling discharge, hearing loss, and possible history of chronic ear infections
Trauma (e.g., temporal bone fracture): Blood-stained or CSF otorrhea following head injury
Foreign body: Often in children, with unilateral discharge and possibly a foul smell

Nasal Discharge (Rhinorrhea)

Viral upper respiratory infection: Clear or mucopurulent discharge, often associated with sneezing and nasal congestion
Allergic rhinitis: Clear, watery discharge with sneezing, itching, and nasal congestion; triggered by allergens
Acute bacterial sinusitis: Thick, purulent discharge, facial pain, and pressure, often following a viral URI
Chronic sinusitis: Persistent mucopurulent discharge, nasal obstruction, and facial discomfort lasting more than 12 weeks
Cerebrospinal fluid (CSF) rhinorrhea: Clear, unilateral discharge, often following head trauma or surgery, worsens with leaning forward
Foreign body: Unilateral, foul-smelling discharge, typically in young children
Nasal polyps: Chronic nasal obstruction and discharge, often with a history of asthma or aspirin sensitivity
Neoplasm (e.g., nasopharyngeal carcinoma): Bloody or unilateral discharge, possible associated symptoms like epistaxis or neck mass

Key Points in History 🥼

Onset and Duration

Acute vs chronic: Acute onset suggests infection or trauma, while chronic may indicate a chronic condition like cholesteatoma or chronic sinusitis
Recurrent episodes: Suggests underlying conditions like chronic otitis media, allergic rhinitis, or chronic sinusitis
Timing: Rhinorrhea worsening with leaning forward suggests CSF leak

Character of Discharge

Color and consistency: Clear discharge suggests viral or allergic causes, while purulent discharge suggests bacterial infection
Odor: Foul-smelling discharge suggests foreign body, cholesteatoma, or chronic suppurative otitis media
Blood-stained: May indicate trauma, neoplasm, or severe infection (e.g., invasive fungal sinusitis)
Unilateral vs bilateral: Unilateral discharge is more concerning for foreign body, neoplasm, or CSF leak

Associated Symptoms

Pain: Ear pain suggests otitis media or externa, while facial pain and pressure suggest sinusitis
Hearing loss: Associated with otitis media, cholesteatoma, or foreign body in the ear canal
Nasal obstruction: Common in allergic rhinitis, sinusitis, nasal polyps, or neoplasm
Fever: Suggests an infectious cause, such as otitis media or bacterial sinusitis
Trauma history: Recent head trauma or surgery increases the suspicion of CSF leak
Systemic symptoms: Consider associated conditions such as asthma (with nasal polyps) or immune compromise (invasive fungal sinusitis)

Background

Past medical history: History of recurrent infections, allergies, or chronic sinus issues
Medication history: Use of intranasal steroids, antihistamines, or recent antibiotics
Family history: Genetic conditions like cystic fibrosis, which may predispose to chronic sinusitis
Social history: Exposure to swimming pools (otitis externa), recent air travel (barotrauma), or occupational hazards
Drug history: Intranasal drug use (e.g., cocaine) can lead to chronic rhinitis or perforation

Possible Investigations 🌡️

Laboratory Tests

Swab for culture and sensitivity: To identify bacterial pathogens in purulent discharge
CSF analysis: If CSF rhinorrhea is suspected, test for beta-2 transferrin
Allergy testing: Consider in chronic rhinitis with suspected allergic component
Blood tests: FBC and inflammatory markers if systemic infection is suspected

Imaging

CT scan of the sinuses: To assess for sinusitis, particularly if chronic or if complications are suspected
MRI: Indicated if intracranial extension is suspected (e.g., in cholesteatoma or invasive fungal sinusitis)
Plain X-ray: May show fluid levels in the sinuses, but less commonly used
Endoscopic examination: Nasal endoscopy for direct visualization of nasal passages, sinuses, and any potential lesions or polyps
Audiometry: If hearing loss is present, to assess the extent and nature of the loss

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