What history should be taken in a patient presenting with ear discharge?

History Taking for Ear Discharge

When evaluating a patient with ear discharge, systematically document the discharge characteristics, associated otologic symptoms, onset pattern, trauma/infection exposures, and prior ear history to distinguish between acute otitis media, chronic suppurative otitis media, otitis externa, and other causes. 1, 2

Discharge Characteristics

• Document the type of discharge: blood, pus, serous fluid, cerebrospinal fluid (CSF), or wax, as each suggests different pathology 3
• Assess duration: discharge lasting more than two weeks suggests chronic suppurative otitis media (CSOM), while acute onset points toward acute otitis media or otitis externa 4, 5
• Determine laterality: unilateral discharge is typical for otitis externa and most ear infections, while bilateral discharge should raise concern for systemic causes 6

Associated Otologic Symptoms

• Ask specifically about hearing loss: document whether it is sudden or gradual, stable or fluctuating, as this helps distinguish conductive from sensorineural causes 1, 2
• Inquire about ear pain (otalgia): severe pain suggests acute infection (otitis externa or acute otitis media), while painless discharge is more consistent with CSOM 1, 3
• Document tinnitus and aural fullness: these symptoms, especially when fluctuating, may indicate Ménière's disease or other inner ear pathology 1, 2
• Ask about vertigo: confirm true rotational vertigo versus vague dizziness, document attack duration, and whether symptoms are positional or spontaneous 1

Onset and Temporal Pattern

• Determine if onset was sudden or gradual: sudden onset with fever and severe otalgia indicates acute otitis media, while gradual onset suggests chronic processes 7, 2
• Ask about recurrent episodes: history of recurrent discharge suggests chronic suppurative otitis media or recurrent otitis externa 3
• Document any fluctuating pattern: fluctuating hearing loss with discharge may indicate Ménière's disease, autoimmune inner ear disease, or other specific conditions 1

Trauma and Infection History

• Ask about recent head trauma: significant trauma coincident with discharge may indicate temporal bone fracture or CSF leak 1, 3
• Document recent water exposure: swimming or water sports predispose to otitis externa 3
• Inquire about foreign body insertion: compulsive scratching, cotton swab use, hearing aids, or objects placed in the ear predispose to infection 3
• Ask about recent upper respiratory infections: these often precede acute otitis media 7
• Document fever and systemic symptoms: presence suggests acute infection requiring different management than chronic discharge 1, 7

Prior Otologic History

• Document previous ear surgeries: especially ventilation tube (grommet) placement, as 26-75% of children with tubes develop acute discharge 7
• Ask about chronic ear infections or otorrhea: history of chronic suppurative otitis media affects management approach 1, 3
• Inquire about prior tympanic membrane perforation: this distinguishes CSOM from acute otitis media with intact membrane 7, 5
• Review prior audiometric testing: previous hearing test results help establish baseline and progression pattern 1, 2

Medication and Exposure History

• Document ototoxic drug exposure: aminoglycosides, loop diuretics, and chemotherapy agents can cause hearing loss and discharge 1, 2
• Ask about current medications: blood pressure medications, diuretics, and chronic vestibular suppressive medications are relevant 1, 2
• Inquire about antibiotic use: recent antibiotic treatment may alter bacterial flora and affect culture results 4, 8

Pediatric-Specific History

• For children, document perinatal risk factors: intrauterine infections (TORCH), birth complications, hypoxia, or ECMO exposure increase risk of hearing loss 2
• Ask about developmental concerns: speech delay or learning problems may indicate chronic hearing impairment from persistent effusion 1, 7
• Inquire about syndromic features: craniofacial anomalies, visual problems, cardiac issues, or renal abnormalities suggest genetic syndromes 2

Family and Social History

• Construct a detailed family pedigree: document hearing status in relatives, consanguinity, and inheritance patterns for genetic causes 2
• Ask about tobacco and caffeine use: these may exacerbate certain conditions like Ménière's disease 1
• Document occupational or recreational noise exposure: chronic loud noise contributes to hearing loss 2

Critical Red Flags to Identify

• Bilateral sudden hearing loss: this is rare and suggests vascular, autoimmune, infectious, or toxic causes requiring urgent evaluation 1
• Focal neurologic findings: facial weakness, dysarthria, severe headaches, or diplopia suggest intracranial complications or stroke 1
• Loss of consciousness: this is never a symptom of Ménière's disease and suggests other serious pathology 1
• Progressive destruction or cranial nerve palsies: these indicate malignant (necrotizing) otitis externa requiring aggressive treatment 3