What is the treatment for swimmer's ear (otitis externa)?

Treatment for Swimmer's Ear (Otitis Externa)

The first-line treatment for swimmer's ear (acute otitis externa) is topical antibiotic eardrops, specifically those containing fluoroquinolones or aminoglycosides, combined with proper ear canal cleaning and pain management. 1

Diagnosis and Clinical Features

Swimmer's ear (acute otitis externa or AOE) is characterized by:

• Rapid onset of ear canal inflammation within the past 3 weeks
• Intense pain and tenderness of the tragus and/or pinna (often disproportionate to visual findings)
• Ear canal edema and erythema
• Possible otorrhea (ear drainage)

The condition is primarily bacterial, with Pseudomonas aeruginosa (20-60%) and Staphylococcus aureus (10-70%) being the most common pathogens 1.

Treatment Algorithm

1. Assess for Modifying Factors

First, evaluate for conditions that may modify treatment approach:

• Perforated tympanic membrane or tympanostomy tubes
• Diabetes
• Immunocompromised state
• Prior radiotherapy

These factors may necessitate specialized care or systemic antibiotics 1.

2. Pain Management

• Provide adequate analgesia (acetaminophen or NSAIDs) as pain is often severe
• Pain typically improves within 48-72 hours of starting treatment 1

3. Ear Canal Preparation

• Perform gentle aural toilet to remove debris and secretions
• Caution: Avoid irrigation in diabetic or immunocompromised patients due to risk of malignant otitis externa 1
• If the ear canal is significantly swollen, place a wick to facilitate medication delivery 1

4. Topical Antimicrobial Therapy

Primary treatment options:

• Fluoroquinolone drops (first-line):

  • Ciprofloxacin 0.2%: Instill contents of one single-dose container into affected ear twice daily for 7 days 2
  • Ofloxacin 0.3%:
    • For patients ≥13 years: 10 drops once daily for 7 days
    • For children 6 months-13 years: 5 drops once daily for 7 days 3

• Aminoglycoside combinations (alternative):

  • Neomycin/polymyxin B/hydrocortisone: Reasonable first-line when tympanic membrane is intact 4

• Important application technique:

  • Warm drops by holding container in hands for 1-2 minutes
  • Patient should lie with affected ear upward
  • Maintain position for 1-5 minutes after instillation
  • For middle ear penetration (with tubes/perforation), pump the tragus 4 times 2, 3

5. When to Consider Oral Antibiotics

• Reserve for cases where infection has spread beyond the ear canal
• Consider for patients at risk of rapidly progressing infection (diabetics, immunocompromised)
• Note: Most oral antibiotics are ineffective against common pathogens (P. aeruginosa and S. aureus) 1

6. Treatment Duration

• Continue eardrops for at least 7 days, even if symptoms resolve sooner
• If symptoms persist beyond 7 days, continue drops until symptoms resolve (maximum additional 7 days) 1
• Consider culture if no improvement after one week 2

Prevention Strategies

To prevent recurrence:

• Avoid cotton-tip applicators for ear cleaning (major risk factor) 5
• Keep ears dry (use ear plugs or swim caps when swimming)
• Use alcohol-based ear-drying solutions after water exposure
• Consider acidifying ear drops before/after swimming for those prone to recurrence 1, 6

Special Considerations

• Diabetic or immunocompromised patients: Monitor closely for necrotizing (malignant) otitis externa, which presents with granulation tissue at the bony-cartilaginous junction and can progress to skull base osteomyelitis 1

• Perforated tympanic membrane or tubes: Use otic preparations that are approved for middle ear use (avoid potentially ototoxic agents) 1

• Children: Swimmer's ear is most common in children 5-14 years old, but over half of all cases occur in adults 6

The burden of AOE is significant, with approximately 2.4 million healthcare visits annually in the US and direct costs estimated at half a billion dollars 6.