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

Treatment of Swimmer's Ear (Acute Otitis Externa)

Topical antibiotic ear drops are the primary treatment for swimmer's ear, with most patients experiencing symptom relief within 48-72 hours and complete resolution by 7 days. 1

First-Line Treatment: Topical Antimicrobial Drops

Drug Selection

• Prescribe topical antimicrobial drops effective against Pseudomonas aeruginosa and Staphylococcus aureus, the most common pathogens 2, 3
• For intact tympanic membrane: Ofloxacin 0.3% otic solution is recommended 2
• For perforated tympanic membrane or tympanostomy tubes: Use only non-ototoxic quinolone drops (ofloxacin or ciprofloxacin) to avoid potential hearing damage 2, 4
• Ciprofloxacin 0.2% otic solution: 0.25 mL (one single-dose container) twice daily for 7 days 5
• Ofloxacin otic solution: 10 drops once daily for 7 days (patients ≥13 years); 5 drops once daily for 7 days (ages 6 months-13 years) 4

Critical Pre-Treatment Steps

Before prescribing drops, clear the ear canal of debris, cerumen, or foreign objects to ensure medication reaches infected tissue 1, 2

• Use gentle lavage with body-temperature water, saline, or hydrogen peroxide 1
• Alternative: suction or dry mopping with cotton-tipped applicator under visualization 1
• CAUTION: In diabetic or immunocompromised patients, avoid irrigation entirely—use only atraumatic aural suctioning under microscopic guidance to prevent necrotizing otitis externa 1, 2

Enhancing Drug Delivery with Ear Canal Wicks

Place a compressed cellulose wick if severe edema prevents drop entry or if the tympanic membrane cannot be visualized 1, 2

• The wick expands when moistened, facilitating drug delivery and reducing edema 1
• May fall out spontaneously within 24 hours to a few days as swelling resolves 1
• If adequate wick placement is impossible, consider adding systemic antibiotics 1

Proper Drop Administration (Critical for Success)

Have someone else administer the drops whenever possible—only 40% of patients self-administer correctly 1

Step-by-Step Instructions 1

• Warm the bottle by holding in hand for 1-2 minutes to prevent dizziness 5, 4
• Lie with affected ear upward
• Fill the ear canal completely with drops
• Remain in this position for 3-5 minutes (use a timer) 1
• Perform gentle to-and-fro movement of the pinna OR press the tragus in/out to eliminate air bubbles 1
• Wipe excess drops after rising

Pain Management

Prescribe analgesics based on pain severity—pain relief is especially critical in the first 48-72 hours before drops take effect 1, 2

• Discuss appropriate oral pain medications with patients 1
• Avoid anesthetic ear drops—they are not intended for active infections and can mask treatment failure 1

Treatment Duration and Follow-Up

• Continue drops for minimum 7 days, even if symptoms resolve earlier, to prevent relapse 1, 2
• Most patients improve within 48-72 hours and have minimal symptoms by day 7 1, 2
• If symptoms persist beyond 7 days, continue drops for maximum 7 additional days (total 14 days) and notify physician 1
• Consider treatment failure if no improvement after 2 weeks 6

Activity Restrictions During Treatment

• Avoid inserting anything into the ear canal, including cotton-tipped swabs 1, 3
• Cover ear canal opening with earplug or petroleum jelly-coated cotton before showering or hair washing 1, 2
• Consult physician before resuming swimming or water activities 1

When to Use Systemic Antibiotics

Reserve oral antibiotics for specific circumstances only 2:

• Extension of infection beyond the ear canal 2
• Diabetes or immunocompromised status 2
• Severe canal edema preventing adequate topical therapy or wick placement 1
• Treatment failure with topical therapy alone 2

The evidence strongly discourages routine use of oral antibiotics for uncomplicated cases—topical therapy alone is effective 6

Special Populations Requiring Extra Vigilance

Diabetic or Immunocompromised Patients

• Monitor carefully for necrotizing (malignant) otitis externa, a life-threatening complication 1, 2
• Avoid ear canal irrigation entirely 1, 2
• Consider systemic antibiotics in addition to topical therapy 2
• Lower threshold for specialist referral 2

Suspected Fungal Infection (Otomycosis)

• Consider in diabetic patients or those failing antibacterial therapy 2, 3
• Requires topical antifungal therapy and debridement 2
• Avoid antibacterial drops that promote fungal overgrowth 2

Common Pitfalls to Avoid

• Overusing oral antibiotics for uncomplicated cases when topical therapy suffices 2, 6
• Using ototoxic preparations (aminoglycosides like neomycin) when tympanic membrane integrity is uncertain 2
• Inadequate pain management in the first 48-72 hours 2
• Failing to remove debris before administering drops, preventing medication penetration 1, 2
• Missing fungal infections, especially in diabetic patients who fail initial therapy 2
• Irrigating ears in diabetic/immunocompromised patients, risking necrotizing otitis externa 1, 2

Evidence Quality Note

The 2014 American Academy of Otolaryngology-Head and Neck Surgery guidelines 1 provide the strongest evidence base for these recommendations. A 2010 Cochrane review 6 found that while most topical treatments show comparable efficacy, acetic acid was less effective than antibiotic/steroid combinations beyond week 1. The evidence consistently supports topical over systemic therapy for uncomplicated cases, with proper drug delivery being as important as drug selection.