What is the first-line treatment (tx) for swimmer's ear (otitis externa)?

First-Line Treatment for Swimmer's Ear (Otitis Externa)

The first-line treatment for swimmer's ear (acute otitis externa) is topical antibiotic eardrops, specifically a fluoroquinolone preparation such as ciprofloxacin 0.2% or ofloxacin 0.3%, administered twice daily for 7 days. 1, 2, 3

Diagnosis and Assessment

Before initiating treatment, assess for:

• Diffuse inflammation of the ear canal
• Ear pain, especially with movement of the tragus or pinna
• Itching, canal edema, erythema, and otorrhea
• Modifying factors that require special consideration:
  • Nonintact tympanic membrane or tympanostomy tubes
  • Diabetes or immunocompromised state
  • Prior radiotherapy 1

Treatment Algorithm

1. Topical Antimicrobial Therapy

• First-line: Fluoroquinolone eardrops

  • Ciprofloxacin 0.2%: 0.25 mL (5 drops) twice daily for 7 days 2
  • Ofloxacin 0.3%: 10 drops once daily for 7 days (adults) or 5 drops once daily (children 6 months-13 years) 3
  • Ciprofloxacin 0.3%/dexamethasone 0.1%: 3-4 drops twice daily for 7 days 4

• Alternative options:

  • Acetic acid preparations
  • Aminoglycoside-containing preparations (only if tympanic membrane is intact) 1

2. Enhance Medication Delivery

• Clean the ear canal of debris before administering drops
• Position patient with affected ear upward during administration
• Maintain position for 1-5 minutes after instillation
• Consider placing a wick if the ear canal is severely swollen 1

3. Pain Management

• Assess pain severity
• For mild to moderate pain: Acetaminophen or NSAIDs
• For severe pain: Consider short-term opioids (48-72 hours) 1, 4

4. Special Situations

When tympanic membrane is not intact or tympanostomy tubes are present:

• Use only non-ototoxic preparations (fluoroquinolones)
• Avoid aminoglycoside-containing products (neomycin/polymyxin B) 1

For diabetic or immunocompromised patients:

• Consider adding systemic antibiotics
• Monitor closely for development of malignant otitis externa
• Avoid ear canal irrigation 1, 4

When to Consider Systemic Antibiotics

Add systemic antibiotics only when:

1. Infection extends beyond the ear canal
2. Cellulitis of the pinna or adjacent skin is present
3. Patient has diabetes or is immunocompromised
4. Signs of severe infection exist (high fever, severe otalgia, toxic appearance)
5. Acute otitis externa persists or worsens despite topical therapy 1

Treatment Duration and Follow-up

• Continue eardrops for at least 7 days, even if symptoms improve sooner
• If symptoms persist beyond 7 days, continue drops until symptoms resolve (maximum additional 7 days)
• Consider fungal infection if patient fails to respond to initial antibiotic therapy 1, 4

Prevention Recommendations

• Keep ears dry (use ear protection when showering/washing hair)
• Consider acidifying ear drops after swimming if recurrent episodes occur
• Avoid ear canal cleaning with cotton-tip applicators
• Avoid swimming in polluted waters 1, 5, 6

Common Pitfalls to Avoid

1. Using ototoxic drops when tympanic membrane is not intact: Always verify tympanic membrane status before prescribing aminoglycoside-containing products 1

2. Inadequate pain control: Pain from acute otitis externa can be severe; ensure appropriate analgesics are prescribed 1

3. Missing fungal infections: Consider otomycosis if standard treatment fails; treat with topical antifungals and debridement 4

4. Failing to recognize malignant otitis externa: Be vigilant in diabetic or immunocompromised patients; signs include granulation tissue at the bony-cartilaginous junction and persistent severe pain 1

5. Improper drop administration: Ensure patients understand proper technique for maximum effectiveness 1, 2, 3