Swimmer’s Ear (OE): Diagnosis and Treatment

Swimmer’s ear is also referred to as otitis externa (OE). It is an inflammatory response in the outer ear (auditory) canal that may involve an infection. There are many types of OE, and it can affect all age groups and is universally painful. Swimming or water exposure is typically blamed, but there are other minor and major reasons one can get OE. Treatment varies, but fortunately, most healthy people respond quickly to treatment.

Our ear canals have a delicate structure. There is an outer portion made of cartilage and a deeper or medial portion that is bone. The junction between the bone and cartilage is particularly sensitive, and often painful. The ear canal is not straight, having an S-shape. It is covered with very thin skin with a normal microflora of bacteria and protected by a natural oil called earwax.

How do I know if I have OE? I have not been swimming.

Pain, often progressing and severe, is the first sign in most cases. Water exposure can occur with water sports such as swimming, snorkeling, and kayaking, but sometimes the culprit is water from bathing.

Signs and symptoms can include:

• Hearing loss.
• Ear pressure, popping, or fullness.
• Drainage or Discharge (this combined with pain can be the only symptoms).
• Itching.
• Bleeding (this can be a result of trauma such as forceful ear cleaning, use of cotton swabs, or from the infection itself).
• Fever (rare).
• Severe deep pain and headache with changes in blood sugar levels (typically in diabetics or those with immonucompromise).

Why is my ear swollen shut?

The key physical finding is that the ear canal can be so swollen that it appears to be swollen shut. Any type of manipulation of the ear itself is painful.

There is redness (erythema), swelling (edema), and narrowing of the ear canal to the point it is filled with white or discolored drainage and there does not seem to be an opening any longer.

Hearing loss is conductive, meaning that no sound can get to the eardrum, and everything can sound muffled. The swelling and redness can extend to the face or neck, causing swelling of adjacent lymph nodes, and in rare cases, it can affect the movement of that side of the face. The latter is a result of a severe type called Necrotizing OE which is rare, occurring in immunocompromised patients such as patients with AIDS or in patients with severe diabetes mellitus. Since Necrotizing OE is unlikely in most patients, it is the topic of another discussion.

What are the other distinct types of OE?

OE is classified as:

• Acute diffuse OE (this is the most common, typically after water exposure).
• Acute localized OE (furunculosis, associated with a hair follicle infection).
• Chronic OE (this is the same as acute but lasting over 6 weeks).
• Eczematous OE (this covers a wide range of dermatologic conditions such as eczema, atopic dermatitis, and psoriasis).
• Otomycosis (this is more common than once thought, involving a fungal infection such as Candida or Aspergillus).

How does OE happen?

Most people think of water being the number one cause, but actually it is not. Moisture can get trapped in the ear canal and that causes skin breakdown. Normally, there are bacteria in the ear canal that find the macerated skin a perfect environment for causing infections.

There are several main categories of causes of OE:

• Alteration of ear canal pH.
• Absence of earwax to protect the environment.
• Trauma.
• Obstruction (most commonly, this is too much wax or the structure of the ear canal is narrow as in children).

Too much or too little ear wax is always a problem. Any type of trauma to the ear canal skin even with routine cleaning, or using earplugs can present a problem

A special case of OE occurs in surfers or those who spend a lot of time in the water. The ear canals themselves can develop exostosis which is a narrowing of their ear canals with an overgrowth of bone.

Some surfers never get rid of the problem until they have minor surgery to reconstruct the ear canals, and of course, stop the water exposure.

What is the treatment of OE?

Over-the-counter analgesics and topical ear drops are most effective. These drops commonly employ acetic acid to lower the pH of the ear canal skin.

An old-fashioned method is to use a homemade mixture of one-third apple cider vinegar, one-third distilled water, and one-third hydrogen peroxide in a dropper. An important note about hydrogen peroxide is that if too much is used, it can cause more ear canal skin irritation and worsen the infection.

Not everyone needs an antibiotic ear drop, which commonly includes a steroid, but those are highly effective. A doctor’s prescription is needed, and it is not usually necessary to place the patient on oral antibiotics.

In fact, despite the demands of some parents to have an oral antibiotic prescription for their children, antibiotics can be contraindicated. Oral antibiotics can promote other infections, especially fungal ones.

In some cases, antifungal treatments, such as those used for athlete’s foot are necessary at the start. Or, treating the underlying skin problem such as eczema or psoriasis is necessary.

The key to the treatment of OE is clearing the ear canal of any ear wax or debris and making sure the ear canal is clear. The point here is that no matter what drops are being used if the treatment cannot get to where it needs to be, it will not work.

Careful examination of the ear canal and debridement are often necessary. Of course, if there is a foreign body present, it must be removed.

It may seem obvious that if any treatment is going to work, the ear must be kept dry. Sometimes, we recommend using a gentle fan or there is a device that can be purchased as an ear “dryer.” Using a hair dryer, particularly in a heat setting, is never a clever idea and can lead to noise exposure and hearing loss.

The most difficult patients can be aquatic athletes. No matter how much the ear is treated, they must stay out of the pool, ocean, or lake for at least 4-5 days for the ear to heal. Many of these patients end up with chronic infections that can cause more long-term consequences. Prevention is paramount.

A final note

What happens if the patient’s OE just does not seem to improve despite therapy and dry ear precautions? In some cases, it is necessary to place a small sponge or a wick in the ear canal. This can be initially painful, but the results can be quick and satisfying.

Using the drops over the wick draws the medicine or acidic solution down into the ear canal and the wick compresses the skin. Most of the time the wick falls out on its own or it is a simple procedure to remove it.

If the OE gets to this point and a wick is needed, an ENT specialist can best perform the procedure. The ENT specialist can also make sure there are no complications such as damage to the eardrum or the development of other more serious problems.