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

Treatment of Otitis Externa (Swimmer's Ear)

Topical antimicrobial therapy is the definitive first-line treatment for uncomplicated acute otitis externa, NOT oral antibiotics, with clinical cure rates of 65-90% within 7-10 days. 1, 2

Initial Management Steps

Aural Toilet (Ear Cleaning)

• Perform aural toilet BEFORE administering any drops to remove debris, cerumen, and inflammatory material—this is essential for medication to reach infected tissues 1, 3
• Use gentle suction, dry mopping, or irrigation with body-temperature water, saline, or hydrogen peroxide 1
• Critical exception: In diabetic or immunocompromised patients, avoid irrigation entirely—use only atraumatic suctioning under microscopic guidance, as irrigation can trigger necrotizing otitis externa 2, 3

Wick Placement

• Place a compressed cellulose wick if severe canal edema prevents drop entry or if most of the tympanic membrane cannot be visualized—the wick expands when exposed to moisture and facilitates drug delivery 1, 2

Topical Antimicrobial Selection

For Intact Tympanic Membrane

• Any FDA-approved topical preparation is acceptable, including: 2
  • Ofloxacin 0.3% (non-ototoxic fluoroquinolone)
  • Ciprofloxacin 0.2% (non-ototoxic fluoroquinolone)
  • Neomycin/polymyxin B/hydrocortisone combinations
• All achieve comparable clinical cure rates of 65-90% within 7-10 days 2
• Topical therapy delivers antimicrobial concentrations 100-1000 times higher than systemic therapy and provides superior outcomes compared to oral antibiotics (cure rates 77-96% vs. 30-67%) 1, 2

For Perforated Tympanic Membrane or Tympanostomy Tubes

• Use ONLY non-ototoxic fluoroquinolone preparations 1, 2, 3:
  • Ofloxacin 0.3% otic solution 4
  • Ciprofloxacin 0.2% otic solution 5
• Never use aminoglycoside-containing drops (neomycin) when tympanic membrane integrity is compromised—these are ototoxic 1, 2

Steroid Addition

• Adding topical corticosteroids to antimicrobial drops may hasten pain relief and reduce inflammation 1, 6
• Caution: Neomycin causes contact dermatitis in 5-15% of patients with chronic otitis externa—avoid in patients with history of contact sensitivity 2

Dosing and Administration

Ciprofloxacin 0.2%

• Instill contents of one single-dose container (0.25 mL) into affected ear twice daily (12 hours apart) for 7 days 5

Ofloxacin 0.3%

• Pediatric patients (6 months to 13 years): 5 drops (0.25 mL) once daily for 7 days 4
• Patients 13 years and older: 10 drops (0.5 mL) once daily for 7 days 4

Proper Drop Administration Technique

• Warm bottle in hands for 1-2 minutes to avoid dizziness from cold solution 1, 2, 5
• Patient lies with affected ear upward 1, 2
• Fill ear canal completely with drops 1
• Maintain position for 3-5 minutes to facilitate penetration 1, 2
• Apply gentle to-and-fro movement of pinna or tragal pumping to eliminate trapped air 2
• Have someone else administer drops if possible—only 40% of patients self-administer correctly during first 3 days 2

Pain Management

• Assess pain severity and prescribe appropriate analgesics—pain in otitis externa can be severe and disproportionate to visual findings 1, 2, 3
• For mild-to-moderate pain: acetaminophen or NSAIDs 1, 2
• For severe pain: consider short-term opioid-containing analgesics for initial 48-72 hours 1
• Inform patients that pain typically improves within 48-72 hours of starting topical therapy 1, 2, 3
• Do NOT use topical anesthetic drops (benzocaine)—they are not FDA-approved for active ear canal infections and can mask disease progression 2

Treatment Duration and Follow-Up

• Minimum treatment duration: 7 days, even if symptoms resolve earlier 2, 3
• If symptoms persist beyond 7 days, continue drops until resolution for maximum of 7 additional days (total 14 days maximum) 2
• Reassess within 48-72 hours if no improvement 1, 2

When to Use Systemic Antibiotics

Oral antibiotics should NOT be used as initial therapy for uncomplicated otitis externa 1, 2, 3

Reserve Systemic Antibiotics For:

• Extension of infection beyond the ear canal (periauricular cellulitis) 1, 2, 3
• Diabetes mellitus or immunocompromised status 1, 2, 3
• When topical therapy cannot reach infected area 1, 2
• Treatment failure after 48-72 hours 1, 2

Systemic Antibiotic Choice

• Fluoroquinolones (ciprofloxacin) are first-line for coverage against Pseudomonas aeruginosa and Staphylococcus aureus, which account for 98% of cases 2
• Most oral antibiotics prescribed for otitis externa are inactive against P. aeruginosa 2

Special Populations

Diabetic or Immunocompromised Patients

• Monitor carefully for necrotizing otitis externa—can present initially with symptoms similar to uncomplicated otitis externa 1, 2
• Consider adding systemic antibiotics even for uncomplicated cases 1, 2, 3
• Avoid ear canal irrigation—use only atraumatic suctioning 2, 3
• Higher risk for fungal infections (otomycosis) 1, 2

Suspected Fungal Infection

• Suspect if white fuzzy exudate with pruritus and discharge, especially in diabetics or after antibiotic use 2
• Treatment: thorough but gentle debridement of fungal debris plus topical antifungal preparations 3-4 times daily for 7-10 days 2
• Avoid antibacterial drops that promote fungal overgrowth 2, 3

Patient Education

• Keep ear dry during treatment—cover ear canal with earplug or petroleum jelly-coated cotton before showering 1, 2, 3
• Avoid inserting cotton swabs or other objects into ear canal 3
• Complete full 7-day course even if symptoms improve earlier 1, 2
• If you taste the eardrops, notify physician immediately—this indicates tympanic membrane perforation 2
• Return for reassessment if no improvement within 48-72 hours 1, 2

Common Pitfalls to Avoid

• Overuse of oral antibiotics for uncomplicated cases—approximately 20-40% of patients inappropriately receive oral antibiotics 1, 2, 3
• Using ototoxic preparations (aminoglycosides) when tympanic membrane integrity is compromised 1, 2, 3
• Inadequate pain management 1, 2, 3
• Failure to remove debris before administering drops 1, 2, 3
• Missing fungal infections, especially in diabetic patients 1, 2, 3
• Never use ear candles—no proven efficacy and can cause harm including ear canal obstruction, hearing loss, and tympanic membrane perforation 1

Treatment Failure: Reassess For

• Inadequate drug delivery due to canal obstruction 1, 2
• Poor adherence to therapy 1, 2
• Allergic contact dermatitis from topical agents (especially neomycin or hydrocortisone) 2
• Fungal co-infection 1, 2
• Incorrect diagnosis 1, 2