Just Keep Swimming! The low-down on Swimmer´s Ear.
Summer is nearly here! Warm weather and summer vacations usually call for splashing in the nearest body of water. In the clinic, we see an increase in external ear infections. Water activities are usually associated with this type of infection, that´s why it´s commonly known as Swimmer´s ear. The medical term is otitis externa.
The ear is anatomically divided into three parts. The outer ear, the middle ear, and the inner ear. When there is an infection of the most exterior part of the ear, we call this otitis externa.
What are the causes?
Bacteria are by far the most common culprits of these infections. Particularly Pseudomonas aeruginosa and Staphylococcus aureus. Fungi infections are less common but can also produce outer ear infections and require a different treatment approach (1). Pseudomonas aeruginosa is commonly found in swimming pools, despite adequate chlorine concentrations (2), and probably the reason why otitis externa usually occurs after splash time in the pool.
On the other hand, some outer ear infections are not related to water exposure. Manipulation of the outer ear with cotton swabs, plastic pen caps, lens legs, or fingernails can result in excoriations or fissures of the skin allowing bacteria to penetrate the underlying connective tissue and proliferate.
Other conditions can be risk factors for outer ear infections. Chronic skin conditions of the outer ear canal, such as psoriasis or eczema. Patients with narrow ear canals or bony growths of the ear canal (exostoses) can also tend to have outer ear infections (3).
What are the symptoms?
- Pain
- Itching
- Redness
- Swelling
- Small amounts of discharge
- Tenderness of the pinna, ear canal, or tragus
- Ear fullness(4)
Tenderness of the pinna, ear canal, or tragus is a distinguishing feature of external otitis. A middle ear infection can present with many of the same symptoms, but very rarely causes tenderness in the ear.
How is Swimmer´s ear treated?
Early-onset and uncomplicated cases can be easily treated with topical antibiotic drops and pain medication.
You need to be evaluated by an otorhinolaryngologist if:
- There is extensive swelling of the ear canal
- The infection is spreading to surrounding tissue
- There is a blocked ear canal that needs clearing
- You have poorly controlled diabetes or are immunocompromised
Cleaning a blocked ear allows drops to penetrate the canal. This is best done with special curettes and a microscope. It´s best to avoid irrigating the ear when there is an active ear infection.
Antibiotic drops are the main treatment for external otitis. A considerably greater concentration of antibiotic can be delivered to the site of infection, there are no systemic side effects and treatment is generally cheap (5).
Sometimes the same swelling can block the outer ear canal. In these cases, a small piece of a gauze strip can be carefully introduced into the ear canal to allow the antibiotic drops to travel through the cotton into the canal. The gauze needs to be removed in 3–4 days at home or in the clinic.
If the infection has spread beyond the outer ear canal, or if you have poorly controlled diabetes, an oral antibiotic may also be prescribed.
The type of antibiotic drop used can vary from case to case. As a general rule, ciprofloxacin ear drops with or without corticosteroids (to help reduce the swelling) are a good choice in most cases. Sometimes a combination of two different types of antibiotic ear drops can be used.
Antiseptic drops have also been proved to be useful. Acetic acid (2%) drops are comparably effective to antibiotic or corticosteroid drops after 7 days of treatment (2).
Pain control is an important part of treatment. Sometimes, I’ve had to prescribe a combination of two or three pain relievers during the first three days of an ear infection until the swelling begins to subside.
Complications of outer ear infections
Fortunately, there are rarely any complications. The overwhelming majority of outer ear infections will resolve without any sequelae. Few cases can result in a perforated eardrum. Seldomly diabetic or immunocompromised patients can develop a malignant otitis externa; also known as a necrotizing otitis externa, which involves destruction of the bone of the skull base (6).
If you don’t feel better after 3–4 days of treatment, you should seek advice from your ENT.
Happy healthy swimming everybody!
