Swimmer’s ear

In this article:

• Treatment
• Cleaning
• Medications for infection
• Medications for pain
• Helping your treatment work
• At the Doctor’s Office
• References

---

Treatment

Swimmer’s ear (also called acute otitis externa, or AOE) is an extremely common condition that affects most people at least once in their lifetime. It is important how to manage it at home and when to see a specialist.

It is easy to take care of the mild swimmer’s ear at home:

• Clean the ear canal carefully with a medicated cotton applicator
• Take pain medication

The consensus of ENT experts made strong recommendations that clinicians should assess patients with AOE for pain and recommend analgesic treatment based on the severity of pain and clinicians should not prescribe systemic antimicrobials as initial therapy for diffuse, uncomplicated AOE unless there is extension outside the ear canal or the presence of specific host factors that would indicate a need for systemic therapy. 

The development group of the top ENT specialists put together a list of recommendations that help physicians and patients to manage swimmer’s ear correctly:

1.  Clinicians should distinguish diffuse AOE from other causes of ear pain (otalgia), fluid in the ear canal (otorrhea), and inflammation of the external ear canal
2. Medical professionals should assess the patient with the moderate swimmer’s ear (diffuse AOE) for other important factors that modify management (ruptured tympanic membrane, ear tube, allergy, diabetes, immunocompromised state, prior radiotherapy)
3. Only topical preparations should be prescribed for initial therapy of swimmer’s ear (diffuse, uncomplicated AOE). Avoid oral antibiotics!
4. Clinical office should take a special effort to train the patient how to administer topical drops and by performing ear canal toilet, placing a wick, or both, when the ear canal is obstructed 
5. Non-ototoxic antibiotics and drugs should be prescribed when the patient has a known or suspected perforation of the tympanic membrane, including a tympanostomy tube to prevent inner ear from getting infected
6. Clinicians should reassess the patient who fails to respond to the initial therapy within 48 to 72 hours to confirm the diagnosis of diffuse AOE and to exclude other causes of illness.

Cleaning

Cleansing the ear canal is perhaps the single most important aspect of treatment. Frequent inspection and drying of the canal are also important. Cleansing can be done by irrigation, gentle suction, and gentle application of cotton swabs, under direct visualization. Removal of discharge and debris can facilitate the application of topical medications. Drying of the ear canal can be done with 70% alcohol. A very gentle cleaning of the ear discharge with acidifying agents (a weak vinegar solution) can help eliminate bacteria. Do not do that too often – additional trauma may increase pain and prolong inflammation. 

Medications for infection

Current American guidelines promote initial topical therapy without systemic antibiotics for uncomplicated swimmer’s ear. Published research studies suggest there is little difference between the various ototopical preparations; and recommend the choice of treatment be based on the specific clinical situation. In practice, this often results in prescribing an antibiotic-steroid formulation for 7 to 10 days.

If the ruptured tympanic membrane is suspected (perforation), neomycin/polymyxin B/hydrocortisone drops, alcohols, and ototoxic drops (aminoglycosides) should be avoided. Fluoroquinolones have no ototoxicity and are the only FDA-approved drug for middle ear use; therefore, they are recommended for the treatment of uncomplicated swimmer’s ear with associated tympanic membrane perforation.

Common topical antibiotics indicated for otitis externa include:

• Polymyxin B, neomycin, and hydrocortisone 3 to 4 drops to the affected ear four times a day
• Ofloxacin 5 drops to the affected ear twice daily
• Ciprofloxacin with hydrocortisone 3 drops to the affected ear twice daily 

Medications for pain

Many OTC medications may be used to help with pain, which is one of the most profound symptoms:

• Tylenol (Acetaminophen)
• Advil (Motrin)
• Aspirin
• Paracetamol

Topical ear drops that contain lidocaine can be prescribed by a doctor. Also, opioids (e.g., oxycodone or hydrocodone) are recommended for severe pain. These should be prescribed with caution due to addictive potential. Since symptoms for uncomplicated swimmer’s ear should improve within 48 hours of initiating topical antibiotic therapy, it is highly advisable to see a doctor if pain continues.

Helping your treatment work

As the ear canal is inside, there are certain tricks you can use to make medicines work better. You may be instructed to use an ear wick. A placement of an ear wick (compressed hydrocellulose or ribbon gauze) is needed to facilitate medication delivery and reduce ear canal edema. The wick is moistened with antibiotic drops and placed into the ear canal. The wick will usually fall out spontaneously, and if necessary, it should be removed by a clinician in approximately two to three days.

---

At the Doctor’s Office

Although not typically done in the primary care setting, ear canal cleansing of discharge may be performed by an ENT specialist for the treatment of acute swimmer’s ear. Gentle lavage or suctioning will allow a doctor to see the tympanic membrane, only if there is no evidence or suspicion of tympanic membrane perforation. This procedure should be avoided in patients with a history of diabetes because it can potentially induce malignant otitis externa.

Doctor may also collect some fluid and debris for the culture to see if there is a resistant bacterium.

It is of great importance for the nurse to educate patients on how to properly administer otic drops and the significance of adherence to treatment. The patient should lie down with their affected side facing upward, apply two to five drops depending on the prescribed drug, and remain in that position for about 3 to 5 minutes.

What are other conditions that can mimic the swimmer’s ear?

In children the ear infection is more common. So, it is important to consider ear infection with ear drainage from a ruptured tympanic membrane as a possibility.

Other conditions that can mimic OE include: 

• Acute otitis media
• Allergic dermatitis
• Surfer’s ear
• Ruptured eardrum
• Contact dermatitis of the ear canal
• Psoriasis
• Furunculosis
• Herpes zoster oticus (Ramsey Hunt syndrome)
• Temporomandibular joint (TMJ) syndrome
• Foreign body in ear canal (very common in kids)
• Carcinoma of the ear canal (rare)

---

References

Clinical practice guideline: acute otitis externa. Rosenfeld RM, Schwartz SR, Cannon CR, Roland PS, Simon GR, Kumar KA, Huang WW, Haskell HW, Robertson PJ.Otolaryngol Head Neck Surg. 2014 Feb;150(1 Suppl):S1-S24. doi: 10.1177/0194599813517083. PMID: 24491310 Review.

Acute otitis externa. Hui CP; Canadian Paediatric Society, Infectious Diseases and Immunization Committee.Paediatr Child Health. 2013 Feb;18(2):96-101. doi: 10.1093/pch/18.2.96.PMID: 24421666 Free PMC article.

Clinical practice guideline: acute otitis externa. Rosenfeld RM, Schwartz SR, Cannon CR, Roland PS, Simon GR, Kumar KA, Huang WW, Haskell HW, Robertson PJ. Otolaryngol Head Neck Surg. 2014 Feb;150(1 Suppl):S1-S24. [PubMed]

American Academy of Otolaryngology–Head and Neck Surgery Foundation. Clinical practice guideline: acute otitis externa executive summary. Rosenfeld RM, Schwartz SR, Cannon CR, Roland PS, Simon GR, Kumar KA, Huang WW, Haskell HW, Robertson PJ., Otolaryngol Head Neck Surg. 2014 Feb;150(2):161-8. [PubMed]

Otitis externa. Wipperman J. Prim Care. 2014 Mar;41(1):1-9. [PubMed]

Otitis externa. Hajioff D, Mackeith S.BMJ Clin Evid. 2008 Jun 26;2008:0510.PMID: 19450296 Free PMC article. Review.

Interventions for acute otitis externa. Kaushik V, Malik T, Saeed SR. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD004740. [PubMed]