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

Treatment for Swimmer's Ear (Acute Otitis Externa)

The first-line treatment for swimmer's ear (acute otitis externa) is topical antimicrobial therapy combined with adequate pain management and aural toilet to clear debris from the ear canal. 1

Diagnosis and Assessment

• Swimmer's ear presents with ear canal inflammation, often with intense tenderness of the tragus and pinna that may be disproportionate to visual findings 1
• The most common pathogens are Pseudomonas aeruginosa (20%-60%) and Staphylococcus aureus (10%-70%), often occurring as polymicrobial infections 1
• Assessment should identify modifying factors that may complicate management, including non-intact tympanic membrane, presence of tympanostomy tubes, diabetes, or immunocompromised state 2

Treatment Algorithm

Step 1: Pain Management

• Pain relief is essential as AOE can cause severe pain due to inflammation near the sensitive periosteum 3
• For mild to moderate pain, use acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) 3
• For severe pain, consider combination therapy with acetaminophen plus an NSAID, or short-term opioid use (48-72 hours) for severe cases 3

Step 2: Aural Toilet

• Clear the ear canal of inflammatory debris, obstructing cerumen, or foreign objects before administering topical medication 2
• Methods include gentle lavage with body-temperature water, saline, or hydrogen peroxide, or atraumatic cleaning with aural suctioning 2
• For severe inflammation, consider analgesic premedication before cleaning 3

Step 3: Topical Antimicrobial Therapy

• Topical antimicrobials are the mainstay of treatment for uncomplicated AOE 3, 2
• Recommended options include:
  • Ciprofloxacin 0.3% with dexamethasone 0.1% otic suspension: 4 drops twice daily for 7 days 4
  • Ofloxacin 0.3% otic solution: 10 drops once daily for 7 days in patients 13 years and older; 5 drops once daily for 7 days in children 6 months to 13 years 5
• Adding a topical steroid to antimicrobial drops may hasten pain relief 3
• For patients with non-intact tympanic membranes or tympanostomy tubes, use only non-ototoxic preparations (such as quinolone drops) 2

Step 4: Ear Canal Wick (if needed)

• Place a wick in the ear canal if edema prevents drop entry or if most of the tympanic membrane cannot be visualized 2
• The wick helps deliver medication deeper into the swollen canal 1

Special Considerations

• Oral antibiotics have limited utility in uncomplicated AOE and should be reserved for specific circumstances 1, 2:
  • Extension of infection beyond the ear canal
  • Patients with diabetes or immunocompromised status
  • When topical therapy cannot reach the infected area or has failed
• Patients should show improvement within 48-72 hours of initiating appropriate therapy; if not, reassessment is necessary 3, 2
• For diabetic or immunocompromised patients, monitor carefully for signs of necrotizing otitis externa and consider adding systemic antibiotics 2

Prevention

• Avoid water exposure during active infection 1
• For prevention in swimmers and those prone to AOE:
  • Use ear plugs or swim caps when swimming 6
  • Apply alcohol-based ear-drying solutions after swimming 6
  • Avoid cleaning ears with cotton swabs or other objects 3
  • Consider prophylactic acidifying drops before and after swimming 1

Common Pitfalls to Avoid

• Overuse of oral antibiotics for uncomplicated cases 2
• Using ototoxic preparations when tympanic membrane integrity is compromised 2
• Inadequate pain management 2
• Failure to remove debris before administering drops 2
• Missing fungal infections, especially in patients with diabetes 2
• Treating for too short a duration - patients should continue drops until symptoms resolve, for a maximum of two weeks 7