What is the treatment for swimmer's ear?

Treatment of Swimmer's Ear (Acute Otitis Externa)

Topical antibiotic ear drops, with or without corticosteroids, are the primary treatment for swimmer's ear and should be used for at least 7 days, even after symptoms improve. 1

First-Line Treatment: Topical Antimicrobial Drops

Topical therapy is the cornerstone of treatment, delivering high concentrations of medication directly to the infection site without systemic side effects. 2 The most common pathogens are Pseudomonas aeruginosa (20-60%) and Staphylococcus aureus (10-70%), making targeted topical therapy highly effective. 1

Recommended Topical Agents

• Fluoroquinolone drops (ciprofloxacin or ofloxacin) are preferred first-line agents, achieving clinical cure rates of 77-96%. 2
• Antibiotic-corticosteroid combination drops are highly effective, as corticosteroids reduce swelling, erythema, and secretions while antibiotics treat the bacterial infection. 2
• Acetic acid 2% with hydrocortisone is effective for mild cases but becomes less effective if treatment needs to extend beyond one week. 1, 3

Critical Administration Technique

Proper drop administration is essential for treatment success. 1, 2 Follow these steps:

• Have someone else administer the drops if possible. 1
• Warm the bottle in your hand for 1-2 minutes before use. 4
• Lie down with the affected ear upward and fill the ear canal completely with drops. 1
• Remain in this position for 3-5 minutes to allow adequate penetration. 1
• Pump the tragus (small cartilage in front of the ear) 4 times in an in/out motion to eliminate trapped air and facilitate penetration. 2, 4

Treatment Duration

• Use ear drops for at least 7 days, even if symptoms improve sooner, to prevent relapse of infection. 1
• If symptoms persist beyond 7 days, continue drops until symptoms resolve for a maximum of 7 additional days. 1
• Most patients feel better within 48-72 hours and have minimal or no symptoms by 7 days. 1

Enhancing Drug Delivery

When the ear canal is obstructed by debris, swelling, or discharge, drug delivery must be optimized. 1

Aural Toilet (Ear Canal Cleaning)

• The clinician should perform gentle cleaning of the ear canal by removing visible secretions, dry crust, or adherent discharge. 5
• Patients should NOT attempt to clean the ear themselves, as this can cause further trauma. 1
• Avoid aggressive irrigation, especially in diabetic or immunocompromised patients. 5

Wick Placement

• Place an ear wick if significant canal edema prevents drop entry or if most of the tympanic membrane cannot be visualized. 5
• Compressed cellulose wick (which expands with moisture) is preferred over cotton balls. 5
• The wick may fall out on its own as inflammation clears—this is a good sign. 1

Pain Management

Pain medicine is especially important for relief in the first few days, until the eardrops begin working. 1

• Systemic analgesics should be prescribed to manage the often severe otalgia. 1
• Pain-relieving (anesthetic) eardrops are NOT recommended because they can mask symptoms of delayed response to therapy. 1

When Oral Antibiotics Are Indicated

Oral antibiotics have limited utility in uncomplicated acute otitis externa and should be reserved for specific situations. 1

Indications for Systemic Antibiotics:

• Cellulitis of the pinna or adjacent skin is present. 1, 5
• Signs of severe infection exist (high fever, severe otalgia, toxic appearance). 1
• Acute otitis externa persists or worsens despite topical therapy with proper administration. 1, 5
• Administration of eardrops is not possible due to local discomfort or lack of tolerance. 1
• Patient has an immunocompromised state or diabetes. 1

Special Considerations

Tympanic Membrane Perforation or Tubes

• If there is a hole in the eardrum, ear tube, or prior ear surgery, use only non-ototoxic fluoroquinolone drops (ciprofloxacin or ofloxacin) that are approved for middle ear use. 1, 2
• Avoid aminoglycoside-containing preparations in these situations. 2
• If you taste the eardrops, this indicates a tympanic membrane perforation—inform your doctor immediately. 1, 2

Diabetic or Immunocompromised Patients

• These patients require special attention as they are at risk for malignant (necrotizing) otitis externa. 1
• Use atraumatic cleaning with aural suctioning under microscopic guidance. 5
• Have a lower threshold for systemic antibiotics. 5

Activity Restrictions and Precautions

Keeping the ear dry is essential during treatment. 1

• Cover the ear canal opening with an earplug or cotton coated with petroleum jelly before showering or hair washing to minimize water entry. 1
• Avoid swimming or water activities during infection and check with your doctor before resuming. 1
• Do NOT insert anything into the ear canal, including cotton-tipped swabs, as this can cause trauma. 1

Common Pitfalls to Avoid

• Stopping treatment when symptoms improve rather than completing the full 7-day course leads to relapse. 2, 5
• Failing to ensure proper drop administration technique results in inadequate drug delivery. 2, 5
• Failing to clean the canal before drops can block medication from reaching the infection site. 5
• Assuming treatment failure too early—allow 48-72 hours for response. 5
• Prescribing oral antibiotics for uncomplicated cases when topical therapy is more effective and avoids systemic side effects. 1

What NOT to Use

Ear candles should NEVER be used in treating acute otitis externa. 1 They have never been shown to be effective but have been shown to cause harm, including obstruction of the ear canal with paraffin, hearing loss, and tympanic membrane perforation. 1

Safety Profile

Eardrops are generally very safe and well tolerated. 1 Only 2-3% of patients report minor adverse effects such as local rash, itching, irritation, or discomfort, but it is rarely severe enough to require stopping the medication. 1, 2 If drops become painful or unexpected symptoms develop, contact your doctor. 1