What doctors wish patients knew about swimmer’s ear

Diving into pools or spending the day at the beach or lake can be the epitome of summer fun, but these aquatic adventures can also come with an unwelcome companion: otitis externa, commonly known as swimmer’s ear. This common affliction can sideline even the most dedicated water enthusiasts with its painful consequences. With the incidence of swimmer’s ear rising during the warmer months, understanding its causes, symptoms and prevention methods is essential for water enthusiasts of all ages. 

The AMA’s What Doctors Wish Patients Knew™ series provides physicians with a platform to share what they want patients to understand about today’s health care headlines.

In this installment, three AMA member physicians took time to discuss what patients need to know about swimmer’s ear. They are:

• Natasha Ahmed, MD, a general pediatrician at Texas Children’s Pediatrics in North Austin.
• Douglas Eisert, MD, a pediatrician at Confluence Health in East Wenatchee, Washington.
• Timothy Spence, MD, a pediatrician at Texas Children’s Pediatrics in North Austin.

Confluence Health and Texas Children’s Pediatrics are members of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.

“In general, there are two types of ear infections. There's a middle ear infection, which is behind the eardrum, further in,” Dr. Spence said, noting “we call ear infections otitis, whether it’s otitis media—meaning the inside or middle part of the ear—or otitis externa, which is the ear canal and is swimmer’s ear.”

“Swimmer’s ear is an infection of the ear canal—the space that leads from the ear seen on the outside of the body to the middle ear behind the ear drum,” echoed Dr. Eisert. “It differs from other ear infections as it does not usually affect the middle ear like other infections do.”

With swimmer’s ear, the most common symptom is “pain, especially with movement of the ear,” Dr. Ahmed said. For example, “if you try to manipulate the ear there will be a lot of discomfort.”

“There can also be itching associated with it, a sensation of fullness and oftentimes there’ll be some drainage associated with it as well,” she said.

“It usually happens within several days to a week of daily swimming or getting the ear wet without making efforts to dry out the ear canal,” Dr. Eisert said.

While swimmer’s ear “is not contagious to other people … children who swim together every day can experience the same problem at the same time,” said Dr. Eisert.

“We always see a surge of swimmer’s ear over the summer,” Dr. Spence said, noting that “the ear canal produces cerumen—which is wax—and that provides water protection, similar to the wax on your car.”

“In the summer with just constant water exposure—particularly in kids because their ear canal doesn't drain as well because it's so small—you get water that just sits there, pools up in the ear canal more commonly,” he explained. “And then that eventually causes irritation and a break in the skin barrier.

“Then that's how the bacteria get in to cause infection,” Dr. Spence added. “It can occur with showering, but typically we think about it from swimming pools, lakes and other bodies of water.”

Additionally, “wax blockage of the canal contributes to moisture build up,” said Dr. Eisert. “A change in pH balance to an alkaline environment also sets up conditions in which bacteria and other germs like to live. This process can break down the skin of the canal and creates the symptoms” of swimmer’s ear. 

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“The most common age range of people affected is from 5 years old to 14 years old,” said Dr. Eisert. “Younger children have smaller, shorter ear canals, and this is the age range when children spend hours of their summer days in the pool.”

“Children and teenagers tend to be more affected, but we have seen that things like frequently wearing earbuds or people who irrigate their ears a lot to get rid of wax are also more prone to swimmer’s ear,” Dr. Ahmed said.

Earbuds, specifically, “can cause irritation in the ear canal. That can be a source of skin-barrier breakdown and infection,” Dr. Spence said. “If your kid’s wearing them all day long and they’re getting irritation in there and then getting ear infections, then that’s probably a good indication to switch to over-the-ear headphones or more of the AirPod-style ones that don’t go in the canal.”

Swimmer’s ear can develop from “something as simple as water from the bath getting in your ear,” Dr. Ahmed said. “But it is definitely more common with swimming pools and lakes and things like that.”

“The idea is that water gets trapped in the ear and then usually bacteria—sometimes fungus—breeds in the ear after that and turns the area red, swollen, inflamed and pretty uncomfortable,” she said.

“Wax blockages, the scratching of the canal with Q-tips, the use of hearing aids or earbuds and shampoos or other chemicals in the ear canal can mimic swimmer’s ear by leading to pain, itching and hearing loss,” Dr. Eisert said. Meanwhile, “a middle ear infection with a perforation—broken ear drum—may cause drainage in the canal and mimic a swimmer’s ear.”

Additionally, “you can have an inner ear infection that for little kids it’s hard for them to localize if it is inside or outside. They just say their ear hurts. So, it can easily be confused for the other type of ear infection,” Dr. Ahmed said. “Then some skin conditions. If you’re having an allergic reaction to a shampoo or cosmetic product that has come in contact with the ear, it can also turn the area red and swollen and irritated.”

“There’s no specific test for swimmer’s ear. It's a diagnosis made purely based on a physical exam,” Dr. Ahmed said. “When we look at the ear, we're looking for redness, we're looking for swelling and discharge.

“And then if we see that the discharge looks maybe a little bit unusual, we may do a culture where we collect a small sample of it and send it off for testing. But that's pretty uncommon,” she added, noting that diagnosis is usually made just by looking at the ear.

“Usually, treatment with acetic acid plus a steroid—such as hydrocortisone—works well for mild swimmer’s ear if given four times per day,” said Dr. Eisert. “If the condition is moderate to severe, then an antibiotic drop mixed with a steroid is often the best choice.”

“The antibiotic helps treat the bacterial component of it and then the steroid helps reduce the inflammatory response that’s occurring and the pain and swelling that you see,” said Dr. Spence. “So, the combination of the two is standard treatment.”

“For more severe conditions that include a deeper skin infection or cellulitis, topical drops in addition to an oral antibiotic may be needed,” said Dr. Eisert, noting “It will take about seven to 10 days to recover depending on the intensity of the condition.”

Typically, “people start feeling better within 48 hours. The treatment duration is usually about seven days or so, but you should start seeing results within 24 or 48 hours,” Dr. Spence said. “If after 48 hours you’re not seeing any improvement, it’s potentially something else or you need to change the antibiotic. But that’s pretty uncommon.”

“If drops are prescribed or used for treatment or prevention, it is important for the patient to understand the best way to place drops,” Dr. Eisert said. “When administering ear drops, there are a few things to remember.

“Lay down on your side or tip your head toward the opposite ear before placing the drops. Place drops in the ear canal,” he explained. Next thing to keep in mind is to “stay on your side for three to five minutes so that the drops can cover your entire ear canal.”

Lastly, “consider placing a cotton ball in the ear to keep drops in the canal,” Dr. Eisert recommended.

“Without medical care once the symptoms begin, it is not going to get better on its own,” Dr. Eisert said, emphasizing that “ignoring this can lead to significant pain and complications.”

“Untreated, swimmer’s ear can lead to infection of the surrounding tissues including the skin or skull,” he said. “One condition called cellulitis occurs when infection spreads to the skin beyond the ear canal. This can cause fever and significant pain.

“This may require oral antibiotics in addition to the topical antibiotics in the canal,” Dr. Eisert added. “If infection spreads to the surrounding bone of the skull, it can be a very serious condition that requires hospitalization given the proximity to the brain.” 

“We don’t recommend swimming for the entire time that you’re using the ear drops, so that’s about seven to 10 days,” Dr. Ahmed said, noting “our swimmers hate that. Especially in the summer, that’s really difficult for a lot of kids to do.”

“Returning to the water too soon will make it very difficult for the ear to improve completely,” Dr. Eisert said.

“Pain control with Tylenol [acetaminophen] or ibuprofen can be effective in helping with the discomfort and should be used to aid in sleeping at nighttime if pain is significant,” Dr. Eisert said.

Such over-the-counter medicines “are fine to help temporarily relieve the symptoms, but this is not going to go away on its own,” Dr. Ahmed said.

To prevent swimmer’s ear, “one of the things that I tell all of my kids who spend time in the pool—which in Austin is all day, every day—is try to dry your ears after you get out of the water,” Dr. Ahmed said. “We typically recommend not using a Q-tip for that, but just using a rolled-up piece of tissue or a towel and tapping on the inner corner of the ear just to suck up any excess moisture.”

Additionally, “you can do a one-to-one mixture of white vinegar and rubbing alcohol and that will help dry up some of that excess moisture in the ear after getting out of a pool or water,” she said.

“There is no need to clear wax from the ear. Older parents tend to think that it's important to eradicate all the wax or they're really worried about if their kids have tons of ear wax, but earwax is actually pretty protective,” Dr. Ahmed said. “In situations like this, it helps form a barrier so that water doesn't actually get into the ear.”

“When you are digging in the ear, you can actually create little areas of trauma where you've torn the skin and then now that's the perfect opening for bacteria to get into the body,” she said.

“We don't recommend anyone ever using—especially in kids—Q-tips to clean out the ear because that ends up just pushing the wax further in there and you can get an impaction that way,” said Dr. Spence. “You don't want to remove that water barrier. That's helping as our ears shed skin.

“As our skin grows, it naturally will push that wax out to prevent excessive buildup because the skin grows from the inside to the outside,” he said. “Some people do produce excessive amounts of earwax and that could be a problem, but in general—for prevention of swimmer’s ear— don't be using Q-tips in the ear.”

“The sooner you start treatment, the quicker the resolution of swimmer’s ear,” Dr. Spence said, noting “I’ve had swimmers here before and I was surprised how painful it was for them. It made sleeping difficult, eating difficult—with the movement of the jaw and irritated.”

While “it’s not an emergency thing and may not require urgent care, it is important to contact your doctor for further guidance,” he said.