What is the likely diagnosis and recommended management for a patient with a ruptured ear presenting with red‑brown drainage and fever?

Red-Brown Drainage from Ruptured Ear with Fever

This presentation is most consistent with acute otitis media (AOM) with spontaneous tympanic membrane perforation, and the patient requires topical fluoroquinolone ear drops (ofloxacin 0.3% or ciprofloxacin 0.2%) plus systemic antibiotics if fever is present or the patient appears systemically ill. 1, 2

Diagnosis

The combination of red-brown ear drainage with fever following ear rupture strongly indicates AOM with tympanic membrane perforation 1. The red-brown color suggests blood-tinged purulent discharge, which is characteristic of bacterial middle ear infection that has perforated through the eardrum 1.

Key diagnostic features to confirm:

• Acute onset of symptoms (typically <48 hours) 2
• Visible perforation of the tympanic membrane on otoscopy 1
• Purulent or blood-tinged otorrhea draining from the ear canal 1, 3
• Fever and systemic signs of infection 1
• History of preceding ear pain that may have improved after rupture 1

Pathogen Considerations

The most likely bacterial pathogens are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1, 4, 5. However, if the patient is older (school-age or adolescent), Streptococcus pyogenes (Group A Strep) must be strongly considered, as it causes more aggressive local disease with higher rates of tympanic membrane perforation and mastoiditis 3. GAS otitis media is characterized by older age, lower rates of fever and respiratory symptoms, but higher rates of spontaneous perforation and complications 3.

Treatment Algorithm

Step 1: Aural Toilet (Essential First Step)

Before any medication, the ear canal must be gently cleaned of debris and drainage 2. Use atraumatic suction under visualization or gentle dry mopping—avoid irrigation if the patient is diabetic or immunocompromised 2.

Step 2: Topical Antibiotic Selection

Use ONLY non-ototoxic fluoroquinolone ear drops when the tympanic membrane is perforated 2:

• Ofloxacin 0.3% otic solution 5-10 drops twice daily for 7-10 days 2
• Ciprofloxacin 0.2% otic solution (with or without dexamethasone) twice daily for 7-10 days 2

Never use aminoglycoside-containing drops (neomycin/polymyxin B) with a perforated tympanic membrane due to ototoxicity risk 2.

Step 3: Systemic Antibiotics (Required in This Case)

Oral antibiotics are indicated because the patient has fever, which signals systemic infection 1. The presence of fever with AOM warrants systemic therapy regardless of age 1, 5.

First-line systemic antibiotic:

• High-dose amoxicillin 80-90 mg/kg/day divided twice daily for children 1
• Amoxicillin-clavulanate 90 mg/kg/day of amoxicillin component if recent antibiotic use (<30 days), treatment failure, or high local resistance 1

Alternative if penicillin allergy:

• Cefdinir or ceftriaxone (if non-type I allergy) 1
• Azithromycin (if type I allergy, though less effective) 1

Duration: 10 days for children <2 years or severe disease; 5-7 days for older children with mild-moderate disease 1

Step 4: Pain Management

Assess pain severity and provide appropriate analgesia 2:

• Mild-to-moderate pain: Acetaminophen or ibuprofen 2
• Severe pain: Short-term opioid-containing analgesics for first 48-72 hours 2
• Pain typically improves within 48-72 hours of starting treatment 2

Step 5: Activity Restrictions

• Keep the ear dry during treatment—cover with petroleum jelly-coated cotton before showering 2
• No swimming until perforation heals and drainage stops 2
• Avoid inserting anything into the ear canal 2

Special Considerations and Red Flags

When to Suspect Group A Streptococcus

If the patient is school-age or older, has spontaneous perforation with minimal fever or respiratory symptoms, strongly consider GAS as the pathogen 3. GAS AOM carries an 11.6 per 1000 risk of mastoiditis—significantly higher than other pathogens 3.

When to Suspect Mastoiditis

Urgent ENT referral is required if any of the following are present 1:

• Postauricular swelling, erythema, or tenderness 1
• Proptosis of the auricle (ear pushed forward) 1
• Severe persistent pain despite 48-72 hours of appropriate therapy 1
• Cranial nerve involvement 1
• Altered mental status or signs of intracranial extension 1

High-Risk Patients Requiring Modified Management

Diabetic or immunocompromised patients require:

• Systemic antibiotics even for seemingly uncomplicated cases 2
• Atraumatic suction only (never irrigation) 2
• Close monitoring for necrotizing otitis externa 2
• Lower threshold for ENT referral 2

Follow-Up and Reassessment

Reassess within 48-72 hours if:

• No improvement in symptoms 2
• Persistent fever beyond 48-72 hours 1
• Worsening pain or drainage 2

Recheck at 2-4 weeks to confirm:

• Perforation healing 1
• Resolution of middle ear effusion 1
• Restoration of hearing 1

Critical Pitfalls to Avoid

• Using aminoglycoside-containing drops with a perforated tympanic membrane (causes ototoxicity) 2
• Failing to provide systemic antibiotics when fever is present 1
• Skipping aural toilet before administering drops (medication cannot penetrate debris) 2
• Missing mastoiditis in patients with postauricular swelling 1, 3
• Inadequate pain management 2
• Allowing water exposure before perforation heals 2