23-year-old with Ear Drainage

A 23-year-old presented to the emergency department (ED) with a chief complaint of ear drainage. He reported “crashing pretty hard” and striking the side of his head upon the water surface while wakeboarding three days earlier.  He had immediate ear pain and reported muffled hearing in the affected ear.  The morning of presentation, he awoke with slightly blood-tinged drainage from the ear. He denied vertigo, ear ringing, nasal drainage, or bleeding.  His exam is notable for significant tenderness with manipulation of his external ear. He had no redness, swelling, or warmth to the surrounding skin. His Wispr digital otoscope exam is shown.

Which of the following is/are likely sources of this patient’s complaints?

A. Tympanic membrane (TM) rupture
B. Otitis externa (OE)
C. Basilar skull fracture
D. A and B

The initial history for this patient is worrisome for traumatic TM (tympanic membrane, “eardrum”) rupture sustained when the side of his head (i.e., ear) slapped the water surface. The abrupt creation of an airtight seal transmits a forceful pressure wave inside the auditory canal and overstretches the TM, resulting in membrane tear. In addition to immediate pain, associated symptoms include bloody drainage, vertigo, and decreased hearing. Otoscopy may demonstrate an acute tear, often in the inferior pars tensa.  However, acute injuries may be accompanied by bloody drainage and TM distortion that make visualization of the ear difficult. 

Our patient had significant drainage which obscured a complete view of the TM.  Notably, the visualized portion appeared thickened and wrinkled, and there were fluid bubbles inferiorly (near a suspected TM defect). These are findings often observed with OE—and with the significant tenderness upon external ear manipulation, this diagnosis was also considered.  It was felt that both traumatic injury and OE from direct “inoculation” with lake water should be managed. The patient was placed on a combined fluoroquinolone-corticosteroid otic drop and had follow-up arranged.  Upon subsequent evaluations, his drainage improved after 72 hours, and symptoms were completely resolved 10 days after the injury.