Drying up swimmer’s ear: Treating acute otitis externa

Each year, more than 6 million cases of swimmer’s ear, or acute otitis externa, will cause kids and teenagers painful infections in the ear canal,-interrupting many vacations and days of summer fun.  Swimmer’s ear is caused primarily by a bacterial infection. Psuedomonas aeruginosa and Staphylococcus aureus are two of the most common pathogens. Symptoms of acute otitis externa include the rapid onset of ear canal inflammation resulting in pain, itching, ear canal swelling and redness, possible decreased hearing, and there may be purulent discharge.  Patients will complain of tenderness and pain when the earlobe is gently manipulated. Swimmer’s ear should be suspected if the patient has been swimming recently, especially in fresh water, or if there is a history of minor trauma to the ear canal, such as the use of cotton swabs or other objects (such as bobby pins) to remove ear wax. Risk factors for acute otitis externa include:

• Anatomic abnormalities
• Use of earplugs, hearing aids
• Dermatological condition such as eczema, psoriasis
• Water in the ear canal from swimming, sweating, humidity, or other prolonged exposure to water.

Key Recommendations for Practice:

Preventing Swimmers Ear:

1. Advise against ear cleaning with cotton swabs or other objects (such as bobby pins) that may cause trauma to the ear canal. Ear plugs are controversial due to the potential for trauma to the ear canal.
2. Gently dry the ear with a blow dryer on the low setting after swimming or bathing.
3. Prophylactic ear drops, such as a 1:1 solution of isopropyl alcohol and white vinegar (acetic acid) can be used or a commercial preparation designed to prevent swimmer’s ear (not covered on TX VDP PDL) can be considered.

Treating Swimmers Ear (acute otitis externa):

1. Topical antibiotic OTIC preparations should be considered first line treatment. OTIC antibiotic and steroid combinations have been shown to be highly successful, with cure rates of 87-97%.
   • A prescription for neomycin/polymixin B/hydrocortisone OTIC suspension, which is available on the TX VDP PDL is a good choice, written as 3-4 drops in the affected ear 3-4 times daily. Neomycin can cause sensitivity reactions and may not be appropriate if tympanic perforation is suspected.
   • If tympanic perforation is suspected, Ciprodex OTIC suspension (Ciprofloxacin/dexamethasone), 3-4 drops in affected ear twice daily for 7 to 10 days, is a good choice and is also available on the TX Medicaid VDP PDL. Ciprofloxacin drops are not ototoxic and are safe to use when a tympanostomy tube or other tympanic membrane opening is present.
2. Patients who have not responded to treatment in 48 to 72 hours should be reassessed.
3. Swimmer’s ear can be painful, and an analgesic such as acetaminophen or an NSAID such as ibuprofen can be prescribed.  Be sure to specify a weight-based dose for each of these medications.
4. During treatment, the ear canal should be kept dry, and patients should be counseled not to swim for 7 to 10 days.
5. Usual duration of treatment is one week, but can be extended to two weeks if symptoms have not fully resolved.
6. Oral antibiotics should ONLY be considered if the infections have spread beyond the ear canal or other risk factors are present.

By Heidi Schwarzwald, M.D.
Chief Medical Officer of Pediatrics, Texas Children’s Health Plan

References:

Clinical Practice Guideline: Acute Otitis Externa. Rosenfeld RM, Schwartz SR, Cannon CR, Roland PS,
Simon GR, Kumar KA, Hunag WW, Haskell HW, Robertson PJ. Otolaryngol Head Neck Surg
. 2014 Feb; Vol. 150(1S) S1–S24. doi: 10.1177/0194599813517083A