Persistent and/or recurrent otorrhea may present a diagnostic and therapeutic dilemma to both the general otolaryngologist and otologist. The goals of this panel presentation are to provide a practical approach to the evaluation and management of problematic ear drainage in the adult patient. The differential diagnosis of persistent otorrhea will be discussed, including common etiologies such as cholesteatoma, refractory otitis externa, and chronic otitis media, in addition to less prevalent causes such as cerebrospinal fluid leak, skull base osteomyelitis, and vasculitides. Case presentations will be used to illustrate the decision-making process behind initial medical therapies, the utility of imaging, and the role of surgical intervention.