Montgomery Medicine No. 726

Swimmer’s Ear

We’re in the middle of swim season and “swimmer’s ear” is becoming more commonplace. Doctors tend to see more of this malady in hot, humid weather, but it can also be the result of other conditions as well.

The medical term for swimmer’s ear is otitis externa, indicating inflammation of the ear canal and less frequently, the external ear. This is in contrast to the more common otitis media, an infection of the middle ear (the air-filled cavity just behind the ear drum).

The number of people who suffer from swimmer’s ear in the U.S. is about four per 1,000 per year. It afflicts males and females in equal numbers and tends to present between seven and twelve years of age, though older people can certainly be affected.

The ear wax (cerumen) that everyone is always trying to clean out of their ears is actually there to protect the external ear canal. There is a delicate balance of too much or too little cerumen. If there is not enough present, the ear canal can dry out, crack, and become infected. If there is too much, the ear canal can become too moist. This leads to swelling and breakdown of the skin lining the ear canal.

The majority of cases of swimmer’s ear are caused by too much wax. This allows water contaminated with bacteria or fungi to enter the ear canal and invade the broken down skin. Since swimmers often swim in contaminated water, they are more prone to develop this problem.

There are other conditions that can lead to otitis externa. Trauma to the ear canal is one of the more common ones. This is where one should heed grandma’s advice to never put anything smaller than your elbow in your ear. Items such as Q-tips, bobby pins, and paper clips do not belong in the ear canal. Repeated use of earplugs, ear buds, or hearing aids can also cause trauma and trapping of moisture.

Other skin conditions such as dermatitis and seborrhea that can increase the risk for infection. People with small ear canals are also prone to more frequent infections.

Species of Pseudomonas bacteria are the most common organisms causing otitis externa. Staphylococci and Streptococci can also cause the infection. Fungi play a role in about five percent of cases.

Most people recover from otitis externa with minimal intervention. However, people with certain medical conditions can develop severe problems. Diabetics and those with compromised immune systems need to be careful. Simple otitis externa can lead to a severe condition called malignant otitis externa.

The malignant form results from the infection spreading to the tissues around the ear. It should be suspected in those who have a lot of redness and/or swelling around the ear. These people need hospitalization for intravenous antibiotics. If left untreated, this condition can be fatal in up to half the cases.

People who have swimmer’s ear typically have some exposure to water. Itching may be the initial symptom followed by worsening pain over the next couple of days. The ear may start to drain white material with a foul odor.

Patients may experience a pressure or fullness in the ear and may also develop hearing loss if the infection causes the ear canal to swell shut. Pain when tugging on the ear or when pushing on the little flap in front of the opening to the ear canal is a reliable physical finding for otitis externa. This usually doesn’t cause pain with middle ear infections.

Treatment is curative over 90 percent of the time. Most people improve in two to three days and are back to normal in a week or so.

There are many treatments available, but prescription antibiotic drops work best. One of the oldest agents around is a milky fluid that contains two different antibiotics and a steroid. However, one of the antibiotics can sometimes cause some hearing loss and the other antibiotic may cause a local allergic reaction.

The antibiotic drops ciprofloxacin and ofloxacin are most commonly recommended. If there is fungal involvement, doctors may prescribe simple acetic acid (vinegar) solutions or topical antifungal medication. Occasionally the pain is so intense that oral narcotics may be required.

Patients who suffer from recurrent bouts of swimmer’s ear should employ preventative measures. A half-and-half mixture of white vinegar and 70 percent isopropyl alcohol works well. A couple of drops in each ear after getting the ears wet can be very effective at prevention. I also recommend directing a blow dryer on the lowest setting into the ear canal after bathing or swimming. Avoid dryers that are noisy that may cause hearing damage.

– Dr. John Roberts is a retired member of the Franciscan Physician Network specializing in Family Medicine.