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Swimmer’s ear is a common name for a medical condition of the ear canal – otitis externa (OE). The reason this type of ear disease got this name is because many people who swim often develop it. Swimmer’s ear is an inflammation, that can be either infectious or non-infectious, of the external auditory canal. In some cases, inflammation can extend to the outer ear, such as the pinna or tragus.
Swimmer’s ear is a common name for a medical condition of the ear canal – otitis externa (OE). The reason this type of ear disease got this name is because many people who swim often develop it. Swimmer’s ear is an inflammation, that can be either infectious or non-infectious, of the external auditory canal. In some cases, inflammation can extend to the outer ear, such as the pinna or tragus.
Otitis externa is a common condition and can occur in all age groups. It is uncommon in patients younger than 2 years old. Its incidence is unknown, but it peaks around the age of 7-14. Approximately 10% of people will develop otitis externa during their lifetime, and the majority of cases (95%) are acute. There is no gender predominance.
Surfer’s ear is a different condition., It is a slowly progressive disease from benign bone growth (exostoses of the external auditory canal) as a result of chronic cold-water exposure.
It is a condition most commonly associated with surfing but can be seen in anyone repeatedly exposed to cold water such as swimmers, divers, kayakers, and participants of other maritime activities.
Although usually asymptomatic and benign, external auditory exostoses (EAE) can cause conductive hearing loss, recurrent otitis externa, otalgia, otorrhea, cerumen impaction, and water trapping. External auditory exostoses are irreversible.
Symptoms
Most common symptoms are:
Significant pain inside an ear canal (or both ears)
Fluid or pus coming out of the ear canal
Fullness sensation and decreased hearing from an affected ear
Headache, sometimes people believe they have a tooth ache if the pain radiates to the jaw
Irritability and crying in children
Swimmer’s ear clinical presentation may vary depending on the stage or severity of the disease. Initially, patients with OE will complain of itching of the ear canal. The pain is inside the ear, and is usually worse with manipulation of the external parts of the ear.
Ear pain is often severe, and is disproportionate to physical exam findings due to irritation of the highly sensitive tissue underneath the thin layer of ear canal skin. It can also present with otorrhea (fluid coming out of the ear), fullness sensation, and hearing loss.
Mild signs and symptoms
Most people have only a mild disease. Indeed, many will only have one-two episodes in their life. The symptoms are limited to:
Ear fullness (sometimes there might be a water trapping due to wax)
Itching and swelling of the ear canal
Mild pain or discomfort
These symptoms usually disappear within 2-3 days, but may come back after another swimming or a shower.
Moderate progression
In certain situations, after a few mild episodes symptoms become worse with subsequent occurrences. Usually, there is an underlying condition, such as allergy, that does not let the swimmer’s ear resolve.
Moderate symptoms are:
Moderate to severe pain
Swelling of the ear canal that partially occludes it, causing decrease of hearing
Some fluid may be seen in the ear canal
Advanced progression
Severe OE symptoms are:
Intense pain of the ear, head and jaw
Lymph nodes around the ear increase in size are painful (lymphadenopathy)
Fever and general malaise
When to see a doctor
Most of people go to see the doctor with their first case of swimmer’s ear because of the intense symptoms and fear that it is an ear infection. A primary care doctor will be able to make a diagnosis and prescribe the treatment. In more severe or repeated cases you will be asked to see a specialist – an ENT doctor or an Allergist.
It is not a bad idea to go to the urgent care or even an ER if the symptoms are intense and the pain is unbearable. If you have any systemic symptoms such as fever or a bad headache – do not delay, as it can be other infections or conditions.
Your ear’s natural defenses
Our body has natural defenses in every organ that communicate with the environment. The ear canal is not an exclusion. Naturally, the wax contains antibacterial and antiviral factors. The ear canal has a tight skin lining which does not let bacteria or chemicals enter inner layers. So, if the ears are healthy and do not have injuries or allergic inflammation, there should be no problem even if you swim.
The ear canal end tightly at the tympanic membrane – a sealed middle ear chamber. The infection from the outer ear canal cannot get inside, if the tympanic membrane is not damaged. Ruptured tympanic membrane opens an access to the inner ear for bacteria. The signs of the ruptured TM can be sometimes confused with the swimmer’s ear.
How the infection occurs
Whenever ear’s natural defense does not work, or the lining gets damaged, the bacteria can get in. Some people develop chronic infections because bacteria find the conditions of the ear canal welcoming – an allergy or trauma creates an entry way and pH that allows bacteria to grow fast and invade.
Having cerumen accumulation in the ear can promote the infection for swimmers. As the water gets into the ear canal it may soak up a dry cerumen plug. As a person tries to get that water out, an injury of the ear canal with the cotton applicator may lead to the inflammation. Wax rocks should not be taken out with any sharp devices. It is best to see a doctor or to get the wax removal kits.
Risk Factors
Swimming is one of the most common risk factors, and it increases the risk five times when compared to non-swimmers. Allergy is another frequent factor leading to the swimmer’s ear. This happens because the allergic reaction (for example, to dust mites or molds) causes wax accumulation, flakiness of the ear canal and leads to pH changes. All these factors lead to normal bacteria overgrowth and inflammation
Other risk factors include:
Humidity
Trauma (cotton swabs, earplugs, wax removing with the curette)
Wearing of hearing aids, ear buds
Skin conditions such as atopic dermatitis, eczema and psoriasis
Contact dermatitis (reaction to topical chemicals)
Complications of the swimmer’s ear are rare, but the disease itself is causes severe discomfort. Acute otitis externa disrupts activities of daily living in approximately 25% of affected patients. AOE can progress to chronic otitis externa, and it can cause canal narrowing (stenosis) and hearing loss. The most common complications of otitis externa are malignant otitis externa and periauricular cellulitis. Other complications include:
Myringitis
Perichondritis
Facial cellulitis
Osteomyelitis of the temporal bone
Prevention
It is important to keep your ear canal healthy and intact. It is best to follow some ear canal care measures:
Do not to put any objects inside the ear (cotton swabs, sticks etc.)
Take an ear ache serious, do not disregard
Prevent ear canal and eardrum injury
Keep your ear canals dry, remove all water after swimming or use ear plugs
Remove ear wax gently with the recommended kits only
Ask for professional consultation with an Allergist if your ears itch and are flaky – it might be dust mites that cause an allergy of the ear canal. Do not scratch ear canal with finger nails or objects!
Do not overuse antibiotics – that creates resistant bacteria which may lead to severe infections.
One of the common ways to get a bad bacteria in the ear is to exchange ear buds when listening to the music or phone. So, do not put someone’s headphones (especially the ones you need to place in the ear canal) into your ear without cleaning them first with alcohol.
Why Do People Get Swimmer’s Ear?
It it often occurs during the summer and in tropical climates. If the water is retained in the canal (especially if you have wax accumulation) after swimming it will increase the risk. The most common cause of acute otitis externa is a bacterial infection. It may be associated with allergies, eczema, and psoriasis.
Pseudomonas aeruginosa and Staphylococcus aureus are the most common pathogens involved in otitis externa. Otitis externa can also occur as a polymicrobial infection, and rarely, it may result from a fungal infection such as Candida or Aspergillus. Various factors can predispose patients to the development of OE.
Diagnosis
Otitis externa is a clinical diagnosis; therefore, a complete history and physical examination are required. Physical examination should include evaluation of the auricle, assessment of surrounding skin and lymph nodes, and otoscopy (ear exam with an otoscope).
Otoscopy will show red and swollen ear canal with flaking and fluid (yellow, white, or gray). A patient is very uncomfortable during the exam due to pain. In some cases, the tympanic membrane cannot be seen due to swelling of the external auditory canal. The differential diagnosis is an ear infection (otitis media), which is usually suspected by the person or parents of the child.
The difference between an external otitis and ear infection (otitis media) is obvious on the exam of the ear, when there is a bulging tympanic membrane and normal ear canal. Evidence of an air-fluid level along the tympanic membrane (middle ear effusion) can be found in the patient with allergies.
Initial testing
In cases with severe symptoms and the ones refractory to empirical treatment, a culture from the ear canal will help navigate treatment. This helps in avoiding the use of inappropriate antibiotics that usually result in developing resistant strains of bacteria.
Further testing
Further sets may include the consultation with the Allergist-Immunologist who will perform different tests to see if the problem with ears is caused by allergy or immune system problems:
Allergy food test
Allergy environments test
Laboratory blood tests for allergy: total IgE, RAST test for multiple allergens
Laboratory blood tests for immunodeficiency: white cell count, immunoglobulins, lymphocyte function assays, vaccination status
Hearing test is recommended, as well as the pneumatic eardrum exam to make sure inflammation does not affect hearing or inner ear integrity.
