What is the best treatment for swimmer's ear (acute otitis externa) in a patient without a perforated tympanic membrane?

Best Treatment for Swimmer's Ear (Acute Otitis Externa)

Topical antibiotic ear drops are the definitive first-line treatment for swimmer's ear—oral antibiotics should not be used for uncomplicated cases. 1

Essential First Step: Clean the Ear Canal

• Before applying any medication, the ear canal must be cleared of debris, cerumen, and inflammatory material through gentle suction, dry mopping, or irrigation with body-temperature water or saline—medication cannot penetrate through debris to reach infected tissue. 1
• Use atraumatic suction under microscopy (not irrigation) if you have diabetes or are immunocompromised, as irrigation can trigger necrotizing otitis externa. 1

First-Line Topical Antibiotic Selection

If You're Unsure About Your Eardrum Status (or Know It's Perforated)

• Use only non-ototoxic fluoroquinolone drops: ofloxacin 0.3% or ciprofloxacin 0.2%—these are safe even if your eardrum is perforated. 1, 2
• Avoid neomycin/polymyxin B drops in this situation because they can damage your inner ear if the eardrum is not intact. 1

If Your Eardrum Is Confirmed Intact

• Any FDA-approved topical preparation works equally well, achieving 65-90% cure rates within 7-10 days. 1, 3
• Options include fluoroquinolones, neomycin/polymyxin B/hydrocortisone, or 2% acetic acid. 1
• Avoid neomycin-containing drops if you have a history of eczema or contact dermatitis—neomycin causes allergic reactions in 13-30% of patients with chronic ear problems. 1

How to Apply Ear Drops Correctly

• Warm the bottle in your hands for 1-2 minutes to prevent dizziness. 1
• Lie with the affected ear facing upward and fill the ear canal completely with drops. 1
• Stay in this position for 3-5 minutes (use a timer)—only 40% of patients do this correctly, and proper technique dramatically improves outcomes. 1
• Gently pump the tragus (the small flap in front of your ear canal) in and out to eliminate trapped air. 1

Treatment Duration

• Continue drops for a minimum of 7 days, even if symptoms resolve earlier—stopping too soon causes relapse. 1, 2, 3
• If symptoms persist beyond 7 days, continue up to 14 days total. 1

Pain Management

• For mild-to-moderate pain: acetaminophen 650-1000 mg every 6 hours or ibuprofen 400-600 mg every 6 hours. 1, 2
• For severe pain: short-term opioid-containing analgesics for the first 48-72 hours. 1
• Pain typically improves within 48-72 hours after starting drops. 1, 2

When You DO Need Oral Antibiotics

Reserve oral antibiotics (fluoroquinolones like ciprofloxacin 500 mg twice daily) only for: 1

• Infection spreading beyond the ear canal (swelling around the ear)
• Diabetes or immunocompromised status
• Severe canal swelling that prevents drops from reaching the infection
• No improvement after 48-72 hours of proper topical treatment

Topical drops achieve 77-96% cure rates versus only 30-67% for oral antibiotics, yet 20-40% of patients inappropriately receive oral antibiotics. 1

Activity Restrictions

• Keep the ear completely dry during treatment—cover with an earplug or petroleum jelly-coated cotton before showering. 2, 3
• Avoid swimming and water exposure until infection resolves. 1, 2
• Do not insert cotton swabs or any objects into the ear canal. 1

When to Seek Reassessment

• Return if symptoms don't improve within 48-72 hours. 1, 2, 3
• Common reasons for treatment failure include inadequate ear cleaning before drops, poor adherence to the 3-5 minute positioning, fungal co-infection (especially in diabetics), or allergic reaction to the drops themselves. 1

Critical Pitfalls to Avoid

• Do not use oral antibiotics for uncomplicated swimmer's ear—they are less effective and contribute to antibiotic resistance. 1
• Do not skip the ear-cleaning step—drops cannot work if debris blocks them. 1
• Do not use aminoglycoside drops (neomycin) if eardrum status is uncertain—they can cause permanent hearing loss. 1
• Do not irrigate the ear if you have diabetes—this can trigger life-threatening necrotizing infection. 1, 3