What are the treatment options for ear crackling and decreased hearing after swimming?

Treatment of Ear Crackling and Decreased Hearing After Swimming

This is acute otitis externa (swimmer's ear), and topical antibiotic ear drops—not oral antibiotics—are the definitive first-line treatment. 1, 2

Immediate Diagnostic Confirmation

The presentation of ear crackling and decreased hearing after swimming is classic for acute otitis externa (AOE), characterized by:

• Ear canal inflammation with tenderness when moving the tragus or pinna (the hallmark physical finding) 3
• Ear canal edema, erythema, and possible discharge 1
• Conductive hearing loss from canal swelling and debris 4
• The "crackling" sensation results from canal edema and accumulated debris 5

Critical first step: Examine the ear canal and assess tympanic membrane integrity, as this determines which topical preparation is safe to use 1, 2

First-Line Treatment Algorithm

Step 1: Aural Toilet (Essential Before Drops)

Gently remove debris from the ear canal using suction, dry mopping, or careful irrigation—but avoid aggressive flushing 1, 2. This step is mandatory because medication cannot reach infected tissues through obstructing debris 1.

Step 2: Topical Antibiotic Selection

If tympanic membrane is intact (most cases):

• Neomycin/polymyxin B/hydrocortisone is a reasonable first-line choice 3
• Apply drops twice daily for 7-10 days 1
• The hydrocortisone component hastens pain relief 2

If tympanic membrane integrity is uncertain or compromised:

• Use ONLY fluoroquinolone preparations (ofloxacin 0.3% or ciprofloxacin) as these are non-ototoxic 1, 2, 6
• Ofloxacin dosing: 10 drops once daily for patients ≥13 years; 5 drops once daily for ages 6 months to 12 years 6
• These provide excellent coverage against Pseudomonas aeruginosa and Staphylococcus aureus (the causative organisms in 98% of cases) 2

Why topical therapy is superior: Achieves 100-1000 times higher drug concentrations at the infection site compared to oral antibiotics, with clinical cure rates of 77-96% versus only 30-67% for oral therapy 1, 2

Step 3: Proper Drop Administration

• Lie on side with affected ear up 6
• Instill prescribed number of drops 6
• Gently pull outer ear upward and backward to straighten the canal 6
• Remain on side for at least 5 minutes after instillation 6
• "Pump" the tragus 4 times to enhance drop penetration 1

Pain Management (Critical Component)

Pain typically improves within 48-72 hours but requires aggressive early management: 1, 2

• Acetaminophen or NSAIDs for mild-to-moderate pain 2
• Stronger analgesics (opioids) may be needed for severe pain in the first 48 hours 1
• Do NOT use topical anesthetic drops (benzocaine) as they are not FDA-approved for active infection and can mask disease progression 2

When Oral Antibiotics Are Indicated (Rare)

Reserve systemic antibiotics ONLY for: 1, 2

• Extension of infection beyond the ear canal (cellulitis of pinna or periauricular tissues)
• Diabetes mellitus or immunocompromised status (higher risk for necrotizing otitis externa)
• Complete canal obstruction preventing topical drug delivery
• Treatment failure after 48-72 hours of appropriate topical therapy

If oral antibiotics are needed: Use fluoroquinolones (ciprofloxacin) for Pseudomonas coverage 2. Most commonly prescribed oral antibiotics (amoxicillin, cephalexin) are inactive against P. aeruginosa and should be avoided 2.

Activity Restrictions and Prevention

During treatment: 1, 6

• Absolutely no swimming until symptoms resolve 1, 6
• Keep ear dry during bathing (use cotton with petroleum jelly to cover canal opening) 1, 6
• Do NOT insert cotton swabs or any objects into the ear canal 1, 2

Prevention of recurrence: 5, 7

• Use alcohol-based ear-drying solutions after water exposure 8
• Consider prophylactic 2% acetic acid drops after swimming 5
• Dry ears with hair dryer on low setting after water activities 5

Expected Clinical Course and Follow-Up

Typical improvement timeline: 1, 2

• Pain should improve within 48-72 hours
• Complete resolution by 7-10 days in 65-90% of cases
• Continue drops for full 7-10 days even if symptoms resolve earlier to prevent relapse 1, 6

Return for reassessment if: 1, 2

• No improvement after 48-72 hours
• Worsening symptoms
• Development of fever, periauricular swelling, or severe pain

Common Pitfalls to Avoid

1. Prescribing oral antibiotics for uncomplicated cases (occurs in 20-40% of patients inappropriately) 2
2. Using ototoxic preparations when tympanic membrane integrity is uncertain 1, 2
3. Failing to perform adequate aural toilet before starting drops 1, 2
4. Inadequate pain management in first 48 hours 1, 2
5. Using neomycin preparations in patients with contact dermatitis history (5-15% of patients are allergic) 2
6. Missing fungal co-infection in patients who fail to respond to antibacterial therapy 2

Special Consideration: Fungal Infection

If symptoms persist beyond 7 days or worsen despite appropriate antibacterial therapy, consider otomycosis (fungal infection), which requires:

• Topical antifungal therapy and debridement 2
• Discontinue antibacterial drops as they promote fungal overgrowth 1, 2