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 pain relief being equally important in the first 48-72 hours. 1

First-Line Treatment: Topical Antimicrobial Drops

Prescribe topical antibiotic drops effective against Pseudomonas aeruginosa and Staphylococcus aureus, which cause 98% of cases. 2

Specific Medication Options:

• For intact tympanic membrane: Ofloxacin 0.3% otic solution is recommended, offering once-daily dosing and superior microbiological eradication 2
• For perforated tympanic membrane or tympanostomy tubes: Use ONLY non-ototoxic quinolone drops (ofloxacin or ciprofloxacin) to avoid permanent hearing loss 1, 2
• Ciprofloxacin 0.2% otic solution: Instill 0.25 mL twice daily for 7 days, achieving 70% clinical cure rates 3

Critical Factors in Choosing Drops:

• Always ask about prior ear surgery, tympanic membrane perforation, or ear tubes - this determines whether you can use potentially ototoxic drops 1
• Consider cost, dosing frequency (once vs. multiple times daily), and patient preference 1
• Inquire about diabetes or immunocompromised status, as these patients require closer monitoring 1, 2

Essential Pain Management

Prescribe analgesics immediately - pain relief is as important as antibiotics in the first 48-72 hours. 1

• Most patients experience severe pain disproportionate to visual findings 2
• Improvement typically occurs within 48-72 hours of starting drops 1
• Avoid anesthetic ear drops - they mask symptoms of treatment failure and are not intended for active infections 1

Optimizing Drug Delivery

Ear Canal Cleaning (Aural Toilet):

Remove debris, cerumen, or foreign objects before administering drops - this is critical for drug penetration. 1, 2

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

Wick Placement:

Place a wick if the ear canal is too swollen for drops to enter or if you cannot visualize most of the tympanic membrane. 1

• Use compressed cellulose (expands with moisture) or ribbon gauze 1
• Moisten the wick with aqueous solution before applying viscous medications 1
• The wick typically falls out spontaneously within 24 hours to a few days as swelling resolves 1
• Never use cotton balls - they fragment and can be retained 1

Proper Drop Administration Instructions:

Patients must follow this technique for drops to work 1:

• Have someone else instill the drops if possible 1
• Lie with affected ear upward and fill the canal completely 1
• Remain in this position for 3-5 minutes (use a timer) - this is non-negotiable for drug penetration 1
• Gently move the ear or press the tragus in/out to eliminate air bubbles 1

Treatment Duration and Follow-Up

Continue drops for at least 7 days, even if symptoms resolve earlier, to prevent relapse. 1

• If symptoms persist beyond 7 days, continue drops for up to 7 additional days (maximum 14 days total) 1
• Reassess if no improvement by 48-72 hours - consider fungal infection, resistant organisms, or incorrect diagnosis 1, 2

When to Use Oral Antibiotics

Reserve systemic antibiotics for specific circumstances only - they are NOT first-line for uncomplicated swimmer's ear. 2

Use oral antibiotics when:

• Infection extends beyond the ear canal 2
• Patient has diabetes or is immunocompromised 2
• Severe canal edema prevents wick placement or adequate cleaning 1
• Topical therapy has failed 2

Activity Restrictions

Instruct patients to keep the ear dry during treatment: 1

• Cover ear canal with earplug or petroleum jelly-coated cotton before showering 1
• Avoid swimming until infection resolves 1
• Never insert cotton swabs or scratch the ear - this worsens inflammation 1

High-Risk Patients Requiring Special Attention

Diabetic or Immunocompromised Patients:

Monitor these patients closely for necrotizing otitis externa - a life-threatening complication. 1, 2

• Avoid ear canal irrigation (use only atraumatic suctioning) 1, 2
• Consider adding systemic antibiotics earlier 2
• Lower threshold for specialist referral 1

Suspected Fungal Infection:

Consider fungal otitis externa if: 2

• Patient has diabetes 2
• Failure to respond to antibacterial therapy 2
• Recent prolonged antibiotic use 2

Treatment requires debridement and topical antifungal therapy 2

Critical Pitfalls to Avoid

• Using ototoxic drops (aminoglycosides) with perforated tympanic membrane or tubes - causes permanent hearing loss 1, 2
• Inadequate pain management - pain is severe and requires immediate attention 2
• Prescribing oral antibiotics for uncomplicated cases - topical therapy is superior 2
• Failing to remove debris before drops - medication cannot penetrate 2
• Irrigating ears in diabetic patients - increases risk of necrotizing otitis externa 1, 2
• Missing fungal infections - especially in diabetics or treatment failures 2
• Stopping drops when symptoms improve - leads to relapse 1

What NOT to Use

Never recommend ear candles - they cause harm (canal obstruction, hearing loss, tympanic membrane perforation) without any proven benefit. 1