Ear Discharge की समझ – Types और Classification

Discharge के Types (Appearance के According)

1. Serous Discharge (Clear, Watery)

• Causes:
  • Early acute otitis media
  • Allergic otitis externa
  • CSF leak (trauma के बाद – very serious)
• Characteristics: पानी जैसा, clear, usually painless

2. Mucoid Discharge (Thick, Sticky)

• Causes:
  • Chronic serous otitis media
  • Eustachian tube dysfunction
• Characteristics: Glue-like consistency, yellowish

3. Purulent Discharge (Pus – Yellow/Green)

• Causes:
  • Acute otitis media with perforation
  • CSOM (Chronic Suppurative Otitis Media)
  • External otitis with infection
• Characteristics: Thick, yellow/green, foul-smelling

4. Bloody Discharge

• Causes:
  • Trauma (cotton bud injury, blast injury)
  • Granulation tissue (chronic infection में)
  • Tumors (rare – glomus tumor, squamous cell carcinoma)
  • Barotrauma (plane travel, diving)
• Red Flag: हमेशा detailed examination जरूरी

5. Cheesy/Foul-smelling Discharge

• Cause: Cholesteatoma (skin cyst in middle ear)
• Characteristics:
  • बहुत तेज़, offensive smell
  • Whitish, cheesy debris
  • Serious condition – bone erosion कर सकता है

Common Causes – विस्तृत विवरण

1. Acute Otitis Media (AOM)

Middle ear का acute bacterial infection।

Pathophysiology:

1. Upper respiratory infection (common cold, flu)
2. Eustachian tube swelling और blockage
3. Middle ear में negative pressure
4. Fluid accumulation
5. Bacterial infection
6. Pus formation
7. Pressure increase → Eardrum perforation
8. Discharge शुरू होना

Common Bacteria:

• Streptococcus pneumoniae (35-40%)
• Haemophilus influenzae (25-30%)
• Moraxella catarrhalis (10-15%)

Clinical Features:

• Severe ear pain initially (perforation के बाद कम हो जाता है)
• High fever (especially in children)
• Hearing loss (temporary)
• Discharge: Profuse, purulent initially, then decreases
• Irritability in children, sleep disturbance

Age Distribution:

• Most common in children 6 months – 2 years
• 50-85% children get at least one episode by age 3
• Can occur in adults but less common

2. CSOM (Chronic Suppurative Otitis Media)

यह chronic middle ear infection है जिसमें persistent discharge होता है।

Definition:

Ear discharge > 6 weeks with tympanic membrane perforation

Types of CSOM:

A. Tubotympanic Type (Safe Type – 80-85%):

• Location: Central perforation (pars tensa involved)
• Discharge: Mucoid/mucopurulent, scanty to profuse
• Smell: Usually not foul
• Complications: Rare (bone erosion नहीं होता)
• Hearing Loss: Conductive type, moderate (40-50 dB)
• Treatment: Medical initially, then surgical (Tympanoplasty)

B. Atticoantral Type (Unsafe Type – 15-20%):

• Location: Attic (superior part) या marginal perforation
• Discharge: Scanty, purulent, FOUL-SMELLING (very characteristic)
• Associated with: Cholesteatoma (almost always)
• Complications: Common और serious
  • Bone erosion (ossicles, mastoid)
  • Facial nerve palsy
  • Labyrinthitis, meningitis, brain abscess
• Hearing Loss: Conductive या mixed, often severe
• Treatment: ALWAYS surgical (Mastoidectomy)

Causes of CSOM:

• Repeated episodes of acute otitis media
• Poor socioeconomic conditions
• Malnutrition
• Overcrowding
• Poor hygiene
• Eustachian tube dysfunction
• Untreated/inadequately treated AOM

3. Otitis Externa (External Ear Infection)

External auditory canal की infection।

Types:

A. Acute Otitis Externa (Swimmer’s Ear):

• Cause: Bacterial (Pseudomonas, Staph aureus) या fungal
• Risk Factors:
  • Swimming (water retention)
  • Hot, humid climate
  • Trauma (cotton bud use)
  • Hearing aid use
• Symptoms:
  • SEVERE pain (worse on chewing, ear movement)
  • Itching
  • Scanty discharge
  • Canal swelling → hearing loss

B. Chronic Otitis Externa:

• Persistent inflammation > 3 months
• Often fungal (Aspergillus, Candida)
• Thick skin, narrowed canal

C. Malignant Otitis Externa:

• NOT a cancer – severe, invasive infection
• Mainly in diabetics, immunocompromised
• Pseudomonas infection spreads to bone
• Medical emergency – can be fatal if untreated
• Needs IV antibiotics, often surgical debridement

4. Cholesteatoma

Middle ear में abnormal skin growth (keratinizing squamous epithelium का cyst)।

Types:

• Congenital: Birth से present (rare)
• Acquired: Chronic ear disease से develop होता है

Mechanism of Bone Erosion:

Cholesteatoma enzymes produce करता है जो bone को destroy करते हैं:

• Ossicles erosion → severe hearing loss
• Mastoid bone destruction
• Labyrinth involvement → vertigo, profound hearing loss
• Facial nerve exposure → facial paralysis
• Tegmen erosion → brain complications

Diagnosis:

• Otoscopy: Attic/marginal perforation, whitish debris
• CT Scan: Extent of disease, bone erosion

Treatment:

ALWAYS surgical – mastoidectomy essential। Medical treatment ineffective।

Complications of Untreated Ear Discharge

A. Intratemporal Complications (Within Temporal Bone)

1. Hearing Loss

• Conductive: Due to perforation, ossicular damage
• Sensorineural: Toxins damaging inner ear
• Mixed: Both components
• Can be permanent if chronic

2. Mastoiditis

• Infection spreading to mastoid air cells
• Acute: Fever, pain, swelling behind ear, ear protrusion
• Chronic: With cholesteatoma, bone destruction
• Needs IV antibiotics ± surgery

3. Labyrinthitis

• Inner ear infection
• Severe vertigo, nausea, vomiting
• Profound sensorineural hearing loss
• Emergency – can cause permanent deafness

4. Facial Nerve Palsy

• Cholesteatoma या infection eroding facial nerve canal
• Sudden onset facial weakness/paralysis
• Needs urgent surgery

B. Intracranial Complications (Brain)

Rare लेकिन LIFE-THREATENING:

1. Meningitis

• Brain covering की infection
• Severe headache, neck stiffness, fever, photophobia
• Altered consciousness
• Needs immediate hospitalization, IV antibiotics

2. Brain Abscess

• Pus collection in brain tissue
• Headache, fever, focal neurological signs
• Needs neurosurgical drainage + antibiotics

3. Lateral Sinus Thrombosis

• Blood clot in major venous sinus
• High-grade fever, severe headache
• Can lead to stroke

4. Extradural/Subdural Abscess

• Pus collection between brain और skull/dura
• Neurological deterioration

⚠️ Warning Signs of Complications:

• Severe headache
• High fever unresponsive to treatment
• Vomiting
• Facial weakness
• Severe vertigo
• Altered consciousness, confusion
• Seizures

Prime ENT Center में Diagnosis

1. Detailed History

• Duration: कब से discharge?
• Nature: Watery, pus, bloody, foul-smelling?
• Quantity: Scanty या profuse?
• Associated symptoms: Pain, hearing loss, vertigo, fever?
• Past history: Previous ear infections, surgery?
• Precipitating factors: Swimming, upper respiratory infection?
• Treatment taken: Ear drops, antibiotics?

2. Otoscopic Examination

Prime ENT Center में हम advanced otoendoscopy use करते हैं।

Findings:

• External Canal: Swelling, discharge, foreign body?
• Tympanic Membrane:
  • Intact या perforated?
  • If perforated: Size, location (central/marginal/attic)
  • Condition: Retracted, bulging, inflamed?
• Middle Ear: Through perforation – mucosa, polyp, cholesteatoma debris, granulations visible?
• Mastoid: Tenderness behind ear?

3. Microscopic/Endoscopic Ear Examination

डॉ. हर्षिता सिंह और डॉ. प्रतीक पोरवाल detailed endoscopic examination करते हैं:

• Magnified view of tympanic membrane
• Assessment of perforation size, edges
• Middle ear visualization
• Ossicular chain status
• Cholesteatoma detection
• Photo/video documentation

4. Aural Swab Culture

• Identify causative organism
• Antibiotic sensitivity testing
• Helps in targeted treatment
• Especially important in chronic cases

5. Audiometry (Hearing Test)

• Pure Tone Audiometry: Type और degree of hearing loss
• Impedance Audiometry: Middle ear function
• Helps in surgical planning
• Baseline for post-op comparison

6. Imaging Studies

CT Scan (HRCT) Temporal Bone:

Indications:

• Chronic ear discharge not responding to treatment
• Suspected cholesteatoma
• Suspected complications
• Pre-operative planning for mastoidectomy

Information Provided:

• Extent of disease
• Bone erosion (ossicles, mastoid, tegmen)
• Scutum erosion (cholesteatoma sign)
• Facial nerve canal integrity
• Labyrinth involvement
• Sigmoid sinus position

MRI:

• If intracranial complication suspected
• Cholesteatoma vs granulation tissue differentiation

Treatment at Prime ENT Center

Medical Management

1. Aural Toilet (Ear Cleaning)

यह सबसे important initial step है।

• Dry Mopping: Cotton wool से discharge absorb करना
• Suction Cleaning: Gentle microsuction under microscope/endoscope
• Syringing: Selected cases में
• Frequency: Daily या alternate days जब तक ear dry न हो जाए

2. Topical Ear Drops

Culture-guided antibiotic drops:

• Applied AFTER thorough cleaning
• Usually 2-3 times daily
• Duration: 1-2 weeks typically
• Some drops contain steroids to reduce inflammation

3. Oral Antibiotics

When indicated:

• Acute otitis media
• Acute exacerbation of CSOM
• External otitis with cellulitis
• Duration as prescribed by doctor

4. Keep Ear Dry

CRITICAL instruction:

• No water entry in ear during treatment
• Use cotton plug with Vaseline while bathing
• No swimming
• Avoid oiling hair (can enter ear)

5. General Measures

• Treat underlying causes: Allergies, adenoids, sinusitis
• Nutritional support
• Boost immunity

Surgical Management

1. Myringoplasty

For: Simple tympanic membrane perforation without ossicular damage

Procedure:

• Graft placement to close perforation
• Graft material: Temporalis fascia (from muscle covering near ear)
• Endoscopic या microscopic approach
• Day care procedure possible

2. Tympanoplasty

For: Perforation with ossicular chain involvement

Types (Wullstein Classification):

• Type I: Myringoplasty (ossicles intact)
• Type II: With malleus damage
• Type III: Incus/stapes involved
• Type IV & V: Complex cases

Procedure at Prime ENT Center:

• General anesthesia
• Duration: 1.5-2.5 hours
• Graft placement
• Ossicular chain reconstruction if needed (using prostheses – PORP, TORP)
• Canal packing
• 1-2 days hospital stay typically

3. Mastoidectomy

For: Chronic ear disease with mastoid involvement, cholesteatoma

Types:

• Cortical Mastoidectomy: Opening mastoid air cells
• Modified Radical Mastoidectomy (MRM): Creating cavity, preserving canal wall या removing it
• Radical Mastoidectomy: Complete cavity creation (rare now)

Goal:

• Complete disease removal
• Create safe, dry ear
• Prevent complications
• Improve/preserve hearing (if possible)

4. Combined Approach Tympanoplasty (CAT)

Mastoidectomy + Tympanoplasty together

Post-operative Care

Immediate (Hospital):

• Head elevated at 30 degrees
• No straining, nose blowing
• Antibiotics, pain management
• Discharge usually day 1-2

First 2 Weeks:

• Keep ear absolutely dry
• Oral antibiotics continued
• Avoid flights, heavy lifting
• Pack removal around day 7-10

3-6 Weeks:

• Regular cleaning और debridement visits
• Ear drops if needed
• Avoid water still

6 Weeks – 3 Months:

• Graft assessment
• Hearing test
• Gradual return to normal activities including swimming (if cleared)

Prevention of Ear Discharge

1. Proper Treatment of Upper Respiratory Infections

• Don’t ignore common cold, especially in children
• Complete antibiotic course if prescribed
• Decongestants help keep Eustachian tube open

2. Ear Care Practices

• NEVER use cotton buds to clean ears – they push wax in, can injure canal/drum
• Clean only outer ear with cloth
• No oil, water instillation at home
• No sharp objects in ear

3. Water Precautions

• Use earplugs while swimming
• Dry ears thoroughly after bathing
• If water enters, tilt head to drain
• Don’t swim in dirty water

4. Early Treatment

• Any ear pain > 24 hours → consult ENT
• Ear discharge → immediate medical attention
• Don’t self-medicate with leftover antibiotics

5. Vaccination

• Pneumococcal vaccine (prevents major cause of ear infections)
• Influenza vaccine (reduces URTIs)

6. Underlying Conditions

• Treat allergies adequately
• Enlarged adenoids in children → consider removal
• Control diabetes (prevents malignant otitis externa)