What are the treatments for otitis externa (swimmer's ear)?

Treatment of Swimmer's Ear (Acute Otitis Externa)

Topical antimicrobial therapy is the definitive first-line treatment for uncomplicated acute otitis externa, NOT oral antibiotics, as it delivers drug concentrations 100-1000 times higher than systemic therapy and achieves clinical cure rates of 65-90% within 7-10 days. 1, 2

Initial Management Steps

Aural Toilet (Essential First Step)

• Remove debris, cerumen, and obstructing material from the ear canal before administering drops to ensure medication reaches infected tissues 3, 1
• Use gentle suction, dry mopping, or irrigation with body-temperature water, saline, or hydrogen peroxide 3, 1
• In diabetic or immunocompromised patients, avoid irrigation and use only atraumatic aural suctioning to prevent complications 4

Topical Antimicrobial Selection

For intact tympanic membrane:

• Use any topical antimicrobial effective against Pseudomonas aeruginosa and Staphylococcus aureus (the causative organisms in 98% of cases) 1, 2
• Options include aminoglycosides, polymyxin B, or fluoroquinolones 3, 1
• Neomycin/polymyxin B/hydrocortisone is a reasonable first-line choice 5

For perforated tympanic membrane or tympanostomy tubes:

• Use ONLY non-ototoxic fluoroquinolone preparations 1, 4, 2
• Ciprofloxacin 0.2% otic solution: instill 0.25 mL (contents of one single-dose container) twice daily for 7 days 6
• Ofloxacin 0.3% otic solution: 10 drops twice daily for patients ≥13 years, or 5 drops once daily for ages 6 months-13 years, for 7 days 7

Proper Drop Administration

• Warm the solution by holding in hands for 1-2 minutes to prevent dizziness from cold solution 6, 7
• Have patient lie with affected ear upward 4, 6
• Fill the ear canal completely with drops 4
• Maintain position for 3-5 minutes (or 1 minute minimum) to facilitate penetration 4, 6
• Apply gentle to-and-fro movement of the ear or press the tragus to help drops penetrate 4

Ear Canal Wick Placement

• Place a wick if canal edema prevents drop entry or if most of the tympanic membrane cannot be visualized 3, 1, 4

Pain Management

• Assess pain severity and prescribe analgesics accordingly, as pain is often severe and limits activities 3, 1
• Pain typically improves within 48-72 hours of starting appropriate treatment 1, 4, 2
• For severe pain, consider short-term opioid-containing analgesics for the initial 48-72 hours 1

When Oral Antibiotics Are Indicated

Oral antibiotics should NOT be used as initial therapy for uncomplicated otitis externa 1, 2. Reserve systemic antibiotics for:

• Extension of infection beyond the ear canal 1, 4, 2
• Diabetic or immunocompromised patients at risk for necrotizing otitis externa 1, 4, 2
• When topical therapy cannot reach the infected area or has failed 1, 2

When systemic antibiotics are needed, use fluoroquinolones (e.g., ciprofloxacin) for coverage against P. aeruginosa and S. aureus 2

Special Populations Requiring Modified Management

Diabetic or Immunocompromised Patients

• Monitor carefully for signs of necrotizing otitis externa (severe pain, cranial nerve deficits, progression of symptoms) 3, 1, 4
• Consider adding systemic antibiotics even for seemingly uncomplicated cases 1, 4
• Higher susceptibility to fungal infections (otomycosis) 2
• Avoid ear canal irrigation 4

Suspected Fungal Infection

• Use topical antifungal therapy and debridement 4, 2
• Avoid antibacterial drops that may promote fungal overgrowth 4, 2
• Consider fungal infection in diabetic patients or those failing antibacterial therapy 1, 2

Treatment Duration and Follow-Up

• Continue eardrops for at least 7 days, even if symptoms improve sooner 4
• Reassess at 48-72 hours if no improvement 2
• If symptoms persist beyond 7 days, continue drops for maximum of 7 additional days 4

Reasons for Treatment Failure

• Inadequate drug delivery due to canal obstruction 2
• Poor adherence to therapy 2
• Incorrect diagnosis 2
• Fungal co-infection 2
• Contact dermatitis from topical agents 2

Patient Education and Activity Restrictions

• Keep the ear dry during treatment 1
• Cover ear canal opening with earplug or petroleum jelly-coated cotton before showering 4
• Avoid scratching or inserting anything into the ear canal, including cotton-tipped swabs 4, 2
• Consult physician regarding swimming during or after treatment 4
• Complete the full course of therapy even if symptoms resolve early 1, 4

Common Pitfalls to Avoid

• Overuse of oral antibiotics for uncomplicated cases (20-40% of patients inappropriately receive oral antibiotics) 1, 2
• Using ototoxic preparations (aminoglycosides, neomycin) when tympanic membrane integrity is compromised 1, 4, 2
• Inadequate pain management 1, 2
• Failure to remove debris before administering drops 1, 2
• Missing fungal infections, especially in diabetic patients 1, 2
• Using ear candles (no proven efficacy and can cause harm) 1
• Avoiding neomycin-containing preparations in patients with contact dermatitis history 2