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

Treatment of Swimmer's Ear (Otitis Externa)

Topical antibiotic eardrops, specifically a fluoroquinolone preparation such as ciprofloxacin 0.2% or ofloxacin 0.3%, administered twice daily for 7 days, are the recommended first-line treatment for acute otitis externa. 1

Diagnosis and Clinical Presentation

Acute otitis externa (AOE), commonly known as "swimmer's ear," is characterized by:

• Inflammation of the external ear canal
• Symptoms including ear pain, itching, discharge, and sometimes hearing loss
• Association with water exposure and warm, humid environments
• Peak incidence during summer months 2

Treatment Algorithm

Step 1: Ear Canal Cleaning

• Thorough cleaning and debridement of debris is essential
• Should be performed under microscopic guidance when possible
• Consider wick placement for obstructed canals 1

Step 2: Topical Antimicrobial Therapy

1. First-line treatment:

   • Fluoroquinolone eardrops (ciprofloxacin 0.2% or ofloxacin 0.3%)
   • Dosing:
     • For children 6 months to 13 years: Five drops once daily for 7 days (ofloxacin) 3
     • For patients 13 years and older: Ten drops once daily for 7 days (ofloxacin) 3
     • For CIPRODEX® (ciprofloxacin 0.3% and dexamethasone 0.1%): Two times daily for 7 days 4

2. Alternative options (if tympanic membrane is intact):

   • Acetic acid preparations
   • Aminoglycoside-containing preparations 1

Step 3: Pain Management

• Assess pain severity
• Prescribe acetaminophen or NSAIDs for mild to moderate pain
• Consider short-term opioids for severe pain 1

Step 4: Administration Technique

1. Warm the bottle in hand for 1-2 minutes to avoid dizziness
2. Position patient with affected ear upward
3. Instill prescribed number of drops
4. Maintain position for 60 seconds
5. Repeat for opposite ear if needed 4, 3

Special Considerations

Perforated Tympanic Membrane

• Use only non-ototoxic preparations to avoid hearing loss and balance disturbance
• Azole antifungals are considered safe choices 1

Fungal Otitis Externa

• Consider if patient fails to respond to antibacterial treatment within 48-72 hours
• Treatment includes thorough cleaning and topical azole antifungals (clotrimazole or miconazole) twice daily for 7-14 days 1

When to Consider Systemic Antibiotics

Systemic antibiotics should be reserved for:

• Extension of infection outside the ear canal
• Diabetic or immunocompromised patients
• History of radiotherapy
• Concurrent acute otitis media 1

Follow-up and Prevention

Follow-up

• Reassess if no improvement within 48-72 hours
• Treatment failure often results from insufficient removal of debris 1

Prevention

• Keep ears dry
• Use ear protection when showering or washing hair
• Avoid ear canal cleaning with cotton-tip applicators
• Consider alcohol-based ear-drying solutions after water exposure 1, 2

Complications to Watch For

• Necrotizing (malignant) otitis externa: An aggressive infection that can invade deeper structures, particularly in diabetic or immunocompromised patients 1
• Persistent dizziness: May indicate extension of infection beyond the external ear canal 1

Swimmer's ear is a common condition with approximately 2.4 million U.S. healthcare visits annually. With proper treatment, patients can expect symptoms to resolve within approximately one week 5, 6.