Ear Discharge (otorrhoea)
Otorrhoea is the drainage of fluid—serous, mucoid, purulent, or bloody—from the external auditory canal, arising from conditions affecting the external ear, middle ear, or rarely the intracranial compartment.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Otitis externa (OE) | Pain on tragal pressure/pinna traction; no hearing loss; debris in EAC [1] | 「㩒住耳仔前面粒嘢痛唔痛？拉吓耳殼痛唔痛？」(Tragal/pinna tenderness) | ~35% |
| AOM (late/perforated) | Preceded by URTI + otalgia → sudden discharge with pain relief; bulging red TM or perforation [2] | 「之前有冇傷風？耳仔先痛之後突然間流嘢出嚟就唔痛？」 | ~20% | |
| CSOM (safe type — tubotympanic) | Persistent TM perforation + recurrent otorrhoea + hearing loss [2] | 「有冇成日流極都唔停？聽嘢差咗？以前有冇穿過耳膜？」 | ~15% | |
| Serious Not To Miss | Cholesteatoma (unsafe CSOM) | Foul-smelling discharge, keratin debris on otoscopy, marginal/attic perforation [2] | 「啲嘢臭唔臭？有冇頭暈、面郁唔到？」 | ~5% |
| Malignant (necrotising) OE | DM/immunocompromised + severe deep ear pain + granulation tissue at bone-cartilage junction | 「你有冇糖尿？耳仔係咪好痛，連瞓覺都痛醒？」 | ~1% | |
| Mastoiditis | Mastoid swelling/tenderness, pinna pushed down and outward → ADMISSION [5] | 「耳仔後面有冇紅腫、㩒落痛？隻耳殼有冇被推咗出嚟？」 | < 1% | |
| NPC (nasopharyngeal carcinoma) | HK endemic; unilateral serous OME/conductive HL + neck mass + blood-stained post-nasal drip [6] | 「頸有冇粒嘢？鼻水有冇帶血？體重有冇跌？」 | < 1% | |
| Pitfalls | Fungal OE | Overuse of antibiotic ear drops → fungal OE; black/white spores on otoscopy [1] | 「有冇用咗好耐耳藥水？」 | ~10% |
| Foreign body in EAC | Children; unilateral foul discharge | 「（小朋友）有冇塞過嘢入耳仔？」 | ~2% | |
| Ramsay Hunt syndrome | Triad: facial paralysis + otalgia + vesicles on auricle/EAC [3] | 「耳仔附近有冇出水泡？塊面有冇歪？」 | < 1% | |
| Masquerades | DM | Predisposes OE, malignant OE, poor healing | 「有冇糖尿？」 | ~5% |
| Drugs (aminoglycosides) | Ototoxicity; prior IV aminoglycoside use [7] | 「有冇打過好強嘅抗生素吊針？」 | < 1% | |
| Trying to Tell Me Something? | Anxiety about hearing loss | Worry about deafness affecting work/relationships | 「你係咪擔心聽力會愈嚟愈差？」 | ~10% |
| Fear of cancer (NPC) | Very common hidden concern in HK Chinese with ear/nose symptoms | 「你有冇擔心係唔好嘅嘢？」 | ~5% |
Ear Discharge (Otorrhoea) — Family Medicine Clinical Test Note
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Greeting, rapport, set agenda | 「你好呀，我係X醫生，今日由我同你傾吓。可唔可以講吓你今日嚟睇咩嘢唔舒服？」(Hello, I'm Dr X, tell me what brought you in today) | Friendly opening; scores interpersonal marks |
| 0:30–2:00 | HPI: characterise the discharge — onset, duration, side, colour, smell, amount, triggers; associated otalgia, hearing loss, tinnitus, vertigo, fever, URTI, water exposure | 「隻耳仔流嘢流咗幾耐？一邊定兩邊？啲嘢係咩色？有冇臭味？有冇耳仔痛、聽嘢差咗、頭暈？之前有冇傷風感冒？有冇游水或者㩒耳仔？」 | Core symptom analysis; discriminates OE vs AOM vs CSOM |
| 2:00–3:00 | Red flags & serious DDx — bloody discharge, facial weakness, mastoid swelling/tenderness, headache, neck mass, weight loss, recurrent epistaxis | 「有冇流血？塊面有冇郁唔到或者歪咗？耳仔後面有冇腫痛？有冇流鼻血、頸有冇粒嘢？」 | Rules out cholesteatoma, mastoiditis, NPC |
| 3:00–3:45 | PMH / DH / Allergy / FH / SH — DM, eczema, prior ear surgery, ear drops, antibiotics, smoking, occupation (noise/water), swimming | 「你有冇糖尿、濕疹？之前有冇做過耳仔手術？用緊咩藥？有冇游水嘅習慣？做咩工作？」 | DM predisposes OE [1]; occupation/water exposure key |
| 3:45–4:30 | ICE — uncover hidden agenda | 「你自己覺得可能係咩問題？（Ideas）你最擔心啲乜？（Concerns）你今日最想我點幫到你？（Expectations）」 | Marks specifically for ICE; hidden agenda often = cancer fear or hearing worry |
| 4:30–5:15 | Functional impact + psychosocial | 「呢個問題影唔影響你返工／返學？瞓唔瞓得著？有冇覺得煩或者擔心？」 | Biopsychosocial scoring |
| 5:15–6:00 | Summarise, signpost, safety-net, close | 「咁我總結吓：你隻（左/右）耳仔流嘢X日，有（症狀）。我想幫你檢查吓隻耳仔。如果用咗藥都冇好轉，或者有發燒、面郁唔到、耳後腫痛，一定要即刻返嚟睇。」 | Summarising + safety-net = high interpersonal marks |
Uncovering the hidden agenda: Ask explicitly 「你今日嚟最主要想解決咩嘢？」— the patient may present with discharge but actually fear hearing loss, cancer (especially NPC in HK), or worry about persistent/recurrent symptoms despite prior treatment.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think Of |
|---|---|---|---|---|
| Onset/Duration | When did the ear discharge start? Acute or chronic? | 「幾時開始流？流咗幾耐？」 | < 6 wk = acute (AOM, OE); ≥ 6 wk = chronic (CSOM) | CSOM if persistent [2] |
| Side | One ear or both? | 「一邊定兩邊？」 | Bilateral → less likely cholesteatoma | Bilateral CSOM, eczema |
| Character | Colour, consistency, smell? | 「啲嘢係咩色？稠定稀？有冇臭味？」 | Foul-smelling discharge → cholesteatoma [2]; purulent → bacterial; cheesy/black → fungal [1] | Cholesteatoma, fungal OE |
| Blood | Any blood in the discharge? | 「有冇帶血？」 | Bloody → trauma, granulation, cholesteatoma, NPC | Cholesteatoma, NPC, carcinoma of EAC |
| Ear pain | Any ear pain? | 「耳仔痛唔痛？」 | OE = painful, especially on tragal pressure; CSOM = usually painless [3] | OE if very painful; AOM |
| Hearing | Any hearing loss? Which ear? | 「聽嘢有冇差咗？邊邊？」 | Otorrhoea + conductive deafness → think middle ear problem [1] | CSOM, cholesteatoma |
| Vertigo/Tinnitus | Any dizziness or ringing? | 「有冇頭暈或者耳鳴？」 | Vertigo → labyrinthine fistula (cholesteatoma complication) | Cholesteatoma, Ménière's |
| URTI | Recent cold/flu? | 「最近有冇傷風感冒？」 | Preceding URTI → AOM via Eustachian tube dysfunction [4] | AOM |
| Water exposure | Swimming or getting water in ear? | 「有冇游水？沖涼有冇入水？」 | Humidity / swimming → OE ("Singapore Ear") [1] | OE |
| Ear instrumentation | Picking/scratching ears? Cotton buds? | 「有冇用棉花棒或者掏耳仔？」 | Scratching/pricking → predisposes OE [1] | OE |
| Facial weakness | Any facial drooping? | 「塊面有冇郁唔到？」 | Red flag → AOM complication (facial nerve palsy) [5] or cholesteatoma | Mastoiditis, cholesteatoma |
| Mastoid area | Pain/swelling behind the ear? | 「耳仔後面有冇腫或者痛？」 | Mastoid swelling & tenderness, pinna pushed down/out → mastoiditis → ADMISSION [5] | Mastoiditis |
| Neck mass/epistaxis | Neck lump? Nosebleed? Post-nasal blood? | 「頸有冇粒嘢？有冇流鼻血或者鼻水帶血？」 | HK endemic: NPC presenting with ear symptoms (Eustachian tube obstruction) [6] | NPC |
| PMH: DM | Do you have diabetes? | 「你有冇糖尿病？」 | DM predisposes OE and malignant OE [1] | Malignant (necrotising) OE |
| PMH: Eczema/Skin | Any eczema or skin disease? | 「有冇濕疹或者皮膚病？」 | Skin disease predisposes OE [1] | OE |
| Drug Hx | Using any ear drops? Antibiotics recently? | 「有冇用耳藥水？食緊咩藥？」 | Overuse of antibiotic ear drops → fungal OE [1]; aminoglycosides → ototoxicity [7] | Fungal OE |
| Allergy | Any drug allergies? | 「有冇藥物敏感？」 | Safety check | — |
| FH | Family history of ear problems or NPC? | 「屋企人有冇耳仔問題或者鼻咽癌？」 | NPC has familial clustering in HK | NPC |
| Social/Occupation | Job? Noise exposure? | 「做咩工作？有冇接觸嘈音？」 | Occupational noise → hearing concern; functional impact | — |
| Functional impact | How does it affect daily life? | 「對日常生活有咩影響？」 | Biopsychosocial marks | — |
| Psychological | Worried? Sleep affected? | 「有冇擔心？瞓得好唔好？」 | Screen anxiety/cancer fear | Hidden agenda |
Case Report Form Answer Builder
CC: Ear discharge (L/R/bilateral) × duration
HPI key points to capture:
- Onset, duration, continuous vs intermittent
- Side (unilateral/bilateral)
- Character: colour (clear/purulent/bloody/foul-smelling), consistency, odour
- Volume, aggravating factors (water, scratching)
- Associated: otalgia, hearing loss, tinnitus, vertigo, fever, URTI symptoms
- Preceding events: URTI, swimming, ear instrumentation, trauma
- Past ear disease/surgery, prior ear drop use
- Red flags: facial weakness, mastoid swelling, neck mass, blood-stained postnasal drip
| Likely RFC Examples | How to Phrase |
|---|---|
| Persistent/worsening ear discharge not improving with self-care | "Persistent left ear discharge for 2 weeks not responding to self-treatment" |
| Worry about hearing loss | "Concern about progressive hearing loss affecting work" |
| Fear of serious disease (NPC/cancer) | "Fear that ear discharge may indicate cancer" |
| Foul-smelling discharge causing social embarrassment | "Foul-smelling ear discharge causing social embarrassment" |
Tip: Pick the ONE reason that best explains why the patient came today, not just the symptom.
| Component | Likely Content | Example Wording |
|---|---|---|
| Ideas | "Patient thinks it may be an ear infection / water got in" | "Pt thinks discharge is due to water entering ear during swimming" |
| Concerns | "Worried about hearing loss / cancer / passing to children" | "Pt worried the discharge may indicate something serious like cancer" |
| Expectations | "Wants ear drops / referral to ENT / hearing test" | "Pt expects a prescription for ear drops and referral to ENT specialist" |
For a typical FM station: The most common presentation is either otitis externa (painful ear + discharge, no hearing loss, history of water/scratching) or CSOM (painless recurrent discharge + hearing loss + TM perforation).
Choose based on stem:
- Acute + painful + no hearing loss + water/scratching trigger → Otitis externa [1]
- Chronic + painless + hearing loss + prior ear disease → CSOM (safe type) [2]
- Acute + post-URTI + otalgia → AOM with perforation [2]
Minimum supporting evidence: State duration, pain character, hearing status, otoscopic finding.
| DDx | Key Discriminator |
|---|---|
| CSOM / Cholesteatoma | Foul-smelling discharge, keratin debris, marginal perforation on otoscopy; conductive hearing loss [2] |
| Otitis externa | Painful (tragal tenderness), no hearing loss, swollen EAC, discharge = debris [1] |
| AOM (perforated) | Preceded by URTI + otalgia, acute onset, purulent discharge, bulging/perforated red TM [2] |
(Adjust based on the stem — always include the most important serious DDx if stem has red flags.)
| Domain | Problem |
|---|---|
| Biological | Conductive hearing loss secondary to CSOM / TM perforation |
| Psychological | Anxiety about potential serious disease (NPC) or progressive hearing loss |
| Social | Foul-smelling discharge causing social embarrassment; occupational difficulty (e.g., cannot swim/work in noisy environment); impaired communication due to hearing loss |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports |
|---|---|---|---|
| Otitis externa | Tenderness on tragal pressure or pinna traction | Press tragus anteriorly; gently pull pinna posterosuperiorly | Pathognomonic for EAC inflammation; NOT seen in middle ear disease [1] |
| CSOM (safe) | Central TM perforation with mucopurulent discharge on otoscopy | Otoscope examination after gentle aural toilet | Persistent non-healing TM perforation = defining feature of CSOM [2] |
| Cholesteatoma (unsafe CSOM) | Keratin debris / retraction pocket at pars flaccida (attic) or marginal perforation | Otoscope — look specifically at posterosuperior quadrant / attic | Keratin debris distinguishes cholesteatoma from simple CSOM [2][3] |
| AOM | Bulging, erythematous TM with loss of light reflex | Otoscope examination | Indicates middle ear effusion/pus under pressure [2] |
| Mastoiditis | Mastoid swelling/tenderness, pinna pushed down and outward | Inspect & palpate behind ear; compare both sides | Classic sign; requires ADMISSION [5] |
| NPC | Firm, non-tender cervical lymphadenopathy (level II) | Palpate anterior and posterior triangles of neck | Most common initial presenting sign of NPC; bilateral involvement common [6] |
| Fungal OE | Black (Aspergillus) or white (Candida) spores/hyphae in EAC | Otoscope examination | Visual diagnosis; history of prolonged antibiotic ear drop use [1] |
| Ramsay Hunt | Vesicles on auricle/EAC + ipsilateral facial palsy | Inspect auricle, EAC; test facial nerve (smile, close eyes) | Herpes zoster oticus triad [3] |
Exam tip: For this station, Rinne and Weber tests should be mentioned to demonstrate conductive vs sensorineural hearing loss — Weber lateralises to the affected ear in conductive loss; Rinne is negative (BC > AC) in conductive loss.
Top Traps That Lose Marks
- Forgetting to ask about NPC red flags — In HK, any adult with new unilateral conductive hearing loss/serous effusion/ear discharge MUST have NPC excluded. Ask about blood-stained postnasal drip, epistaxis, neck mass, diplopia, weight loss [6].
- Confusing OE and AOM — OE = painful on tragal pressure, normal TM; AOM = preceded by URTI, bulging TM, hearing loss [1][2].
- Missing cholesteatoma — If discharge is foul-smelling and chronic, always ask about vertigo and facial weakness (complications of erosion) [2].
- Not asking about DM — DM predisposes to OE AND malignant (necrotising) OE, which is life-threatening [1].
- Forgetting ICE — These are specifically tested. The hidden agenda is often cancer fear or hearing worry.
- Not mentioning otoscopy as the key physical examination — Even though you don't perform it in the station, state it as the supporting sign.
- Confusing "safe" vs "unsafe" CSOM — Safe = central perforation, tubotympanic; Unsafe = marginal/attic perforation ± cholesteatoma [2].
"Must Not Miss" Red Flags Requiring Urgent Referral:
| Red Flag | Suspect | Action |
|---|---|---|
| Mastoid swelling/tenderness, pinna pushed down/out | Mastoiditis | ADMISSION for IV antibiotics, CT, surgery [5] |
| Facial nerve palsy with ear discharge | Cholesteatoma / complicated AOM | Urgent ENT referral |
| Bloody discharge + neck mass + post-nasal blood | NPC | Urgent ENT referral for nasopharyngoscopy + biopsy [6] |
| DM + severe deep ear pain + granulation tissue at bone-cartilage junction | Malignant (necrotising) OE | Urgent ENT referral, CT temporal bone |
| Vertigo with chronic ear discharge | Labyrinthine fistula (cholesteatoma complication) | Urgent ENT referral |
Shortest Safe Management / Safety-Net Line:
「如果用咗藥兩至三日都冇好轉，或者出現發燒、耳後腫痛、面郁唔到、頸有粒嘢，一定要即刻返嚟覆診或者去急症室。」 (If no improvement in 2–3 days, or if you develop fever, swelling behind ear, facial weakness, or neck lump, come back immediately or go to A&E.)
High Yield Summary
What to ASK: Onset/duration, side, character (colour/smell), pain (tragal tenderness?), hearing loss, vertigo, URTI, water/scratching, facial weakness, mastoid area, neck mass, postnasal blood, DM, eczema, ear drops use, ICE.
What to WRITE: CC with side + duration; RFC = why today (not just the symptom); ICE with patient's own words; Dx supported by otoscopic finding + key history; 3 DDx with discriminators; biopsychosocial problems including hearing impact + cancer worry + social embarrassment.
What NOT TO MISS: NPC (HK endemic — unilateral serous OME + neck mass + blood postnasal drip); cholesteatoma (foul smell + marginal perforation); mastoiditis (post-auricular swelling → ADMISSION); malignant OE in diabetics; fungal OE from antibiotic ear drop overuse.
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: GC 214. Common ear diseases and hearing loss.pdf (p6 — Otitis externa, predisposing factors, fungal OE) [2] Lecture slides: GC 214. Common ear diseases and hearing loss.pdf (p9, p11 — CSOM, cholesteatoma, AOM) [3] Senior notes: MBBS Final MB (Pediatrics) (Felix PY Lai).pdf (p118 — AOM/CSOM clinical features, DDx including Ramsay Hunt) [4] Senior notes: MBBS Final MB (Medicine) (Felix PY Lai).pdf (p136 — Eustachian tube dysfunction, sinusitis and otalgia) [5] Lecture slides: CFB WCS29_Common ENT conditions 2023.pdf (p30 — Otological infection, mastoiditis management) [6] Senior notes: MBBS Final MB (Surgery) (Felix PY Lai).pdf (p251 — NPC clinical manifestation, EBV, neck mass) [7] Senior notes: Block A - Drugs and the Kidney.pdf (p10 — Aminoglycoside nephrotoxicity and ototoxicity)
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