What is Otitis Externa (Swimmer’s Ear)?
Otitis externa, also known as OE or “swimmer’s ear”, is a condition where the external part of the ear canal becomes inflamed. This inflammation can be caused by an infection or other non-infectious reasons, and in certain instances, it may also affect the outer ear parts like the pinna or tragus. OE comes in two forms: acute, lasting less than six weeks, and chronic, lasting more than three months.
Interestingly, this condition often emerges during the summer or in tropical climates and is elevated by having leftover water in one’s ears, hence the nickname “swimmer’s ear”. The main reason for acute otitis externa is typically a bacterial infection. It can also be linked to allergies, eczema, and psoriasis.
What Causes Otitis Externa (Swimmer’s Ear)?
Otitis externa, a condition commonly known as swimmer’s ear, often happens because of bacteria, particularly two types known as Pseudomonas aeruginosa and Staphylococcus aureus. In some instances, multiple types of microbes may be involved, and in rarer cases, it can even stem from a fungal infection such as Candida or Aspergillus.
Otitis externa may occur due to several risk factors. For instance, people who frequently swim are five times more likely to get it compared to those who don’t swim. But it’s not just swimming – other things like humid conditions, physical damage to the ear or the use of external devices such as cotton swabs, earplugs, or hearing aids can also increase risk.
People with skin conditions like eczema or psoriasis, those with narrow ear canals or blocked ear canals (due to earwax or foreign objects), and those who have had radiotherapy or chemotherapy, may also be more susceptible. Stress can play a part, too, as can conditions that weaken the immune system. Thus, anyone with these risk factors should be particularly careful about preventing swimmer’s ear.
Risk Factors and Frequency for Otitis Externa (Swimmer’s Ear)
Otitis externa, often called swimmer’s ear, is a common condition that can affect people of all ages, although it’s unusual in kids under 2 years old. It’s hard to pin down exactly how common it is, but it’s especially common around the ages of 7 to 14. In fact, about 10% of people will have otitis externa at some point in their lives, and most of these cases (95%) will be acute, or short-term. It’s equally common in both men and women. Otitis externa is typically seen more in the summer and in hot, humid climates.
- Otitis externa can occur at any age, but it’s rare in children under 2.
- It is especially common in people between the ages of 7 to 14.
- About 10% of people will experience otitis externa in their lifetime.
- The vast majority of cases (95%) are acute.
- This condition affects both men and women equally.
- It is usually more common in the summer and in hot, humid climates.
Signs and Symptoms of Otitis Externa (Swimmer’s Ear)
Otitis externa, or inflammation of the outer ear, is usually diagnosed by a doctor based on a patient’s medical history and a physical exam. Physicians typically look at the ear, the skin around it, and nearby lymph nodes, and use an instrument called an otoscope to look into the ear canal. They might see swelling and redness, which often comes with a certain type of ear wax that can be yellow, white, or gray. Sometimes, the eardrum might appear reddish or hard to see because of the swelling.
If a patient has additional problems like a filled ear-flap (middle ear effusion), it may suggest a concurrent middle ear infection.
How otitis externa presents can vary, often depending on how severe the infection is. Some initial symptoms brought by affected people may include itchiness and ear pain, which can worsen when touching parts of the ear like the small piece right in front of the ear canal (tragus) or the outer layer (pinna). The pain, which can be quite intense compared to what the physical examination shows, is due to the irritation of the sensitive tissue beneath the thin skin of the bony ear canal. You might also have symptoms like ear discharge, a feeling of fullness in the ear, and hearing loss.
If the infection spreads beyond the external ear canal, you might also develop systemic signs like a high fever above 101 F (38.3 C) and a general feeling of unwellness.
Otitis externa can also be classified into mild, moderate, and severe stages:
- Mild: Itching, slight discomfort, some swelling of the ear canal
- Moderate: Partial blockage of the ear canal
- Severe: Ear canal is completely blocked due to swelling, often accompanied by intense pain, swollen lymph nodes, and fever
Testing for Otitis Externa (Swimmer’s Ear)
Otitis externa, also known as ‘swimmer’s ear’, is typically identified by a doctor through a physical exam, and there’s usually no need for routine lab tests or ear swab cultures for straightforward cases. However, if the condition keeps coming back, or doesn’t respond to treatment, especially in patients with weakened immune systems, then your doctor might recommend cultures. For people with severe symptoms, blood tests for blood sugar levels and HIV might be considered.
Treatment Options for Otitis Externa (Swimmer’s Ear)
Most people diagnosed with otitis externa, an infection of the outer ear, can manage the condition at home. The usual treatment includes pain relievers and ear drops that contain antibiotics. Pain can be very severe, so it is important to manage it properly. Over-the-counter medications like acetaminophen or anti-inflammatory drugs can help with mild to moderate pain. For severe pain, opioid medications, such as oxycodone or hydrocodone, can be used, but usually in small amounts. In these cases, if the pain doesn’t improve within 48 to 72 hours, a visit to a primary healthcare provider is strongly suggested.
Ear drops with antibiotics are generally safe and effective. Many studies have revealed that they work better than placebo. Some studies also suggest that ear drops with steroids can lessen inflammation more effectively and relieve pain faster. No matter which ear drop is used, the symptoms typically get better in about a week or so, with a 65% to 90% recovery rate.
Commonly used ear drops for otitis externa include:
- Polymyxin B, neomycin, and hydrocortisone – 3 to 4 drops in the affected ear, four times a day
- Ofloxacin – 5 drops in the affected ear, twice daily
- Ciprofloxacin with hydrocortisone – 3 drops in the affected ear, twice daily
If there is significant swelling in the ear canal, a small piece of material called an ear wick can be inserted to help deliver the medication and reduce swelling. The wick usually falls out by itself after a few days or can be removed by a healthcare provider.
Certain ear drops shouldn’t be used if there’s a risk that the eardrum may be perforated, or damaged. Fluoroquinolones are safe in such cases as they don’t damage the ear and are even approved by the FDA for use in the middle ear.
In some cases, it’s recommended to clean the external ear canal, although this is usually not done in the primary care setting. This cleaning should be done very gently and only if the eardrum isn’t damaged. People with diabetes should not have their ear canals cleaned this way, as it can lead to a more serious condition called malignant otitis externa.
Oral antibiotics aren’t generally helpful for otitis externa, and abusing them can lead to bacteria becoming resistant to the antibiotics. These medications might be needed for people with diabetes, HIV/AIDS, suspected malignant otitis externa, or an additional middle ear infection.
Lastly, topical antifungal agents aren’t typically used for treating otitis externa, except in cases where a fungal infection is suspected based on ear examination or culture results.
What else can Otitis Externa (Swimmer’s Ear) be?
Doctors should consider a variety of possible causes when a patient comes in with ear pain and/or discharge from the ear, especially in children. One common cause in children could be a middle ear infection that has caused the eardrum to burst, leading to ear drainage. Since it might be hard to tell whether the issue is actually an outer ear infection or a middle ear infection with a burst eardrum, it’s often wise to treat both conditions if there’s any doubt. Other potential causes of symptoms resembling an outer ear infection include:
- Acute middle ear infection
- Skin inflammation of the ear canal due to allergies
- Psoriasis
- A type of skin infection called furunculosis
- A condition caused by the chickenpox virus affecting the ear (Ramsey Hunt syndrome)
- Pain in the jaw joint (Temporomandibular joint syndrome)
- Something stuck in the ear
- Ear canal cancer
What to expect with Otitis Externa (Swimmer’s Ear)
Patients who receive treatment with antibiotic or steroid drops for an ear condition can typically expect their symptoms to last about 6 days from the start of the treatment. Many instances of this condition will naturally get better during the acute, or initial, period. However, the condition can come back again in the future; how often this occurs is not yet known. There is also a risk that chronic inflammation from this condition could lead to hearing loss or narrowing of the ear canal, and this can happen even after a single episode.
Possible Complications When Diagnosed with Otitis Externa (Swimmer’s Ear)
Acute otitis externa, or inflammation of the external ear, can disrupt daily activities for about 25% of the people it affects. If not dealt with, it can become chronic, narrow the ear canal, and eventually cause hearing loss. The most common complications of this condition include dangerous ear infections and infections around the ear. There are also various other complications:
- Myringitis
- Perichondritis
- Facial cellulitis
- Osteomyelitis of the temporal bone
Malignant or necrotizing otitis externa (NOE) is a serious condition often found in people with weak immune systems and older adults with diabetes. NOE happens when an infection spreads to the bone behind the ear and is usually caused by a type of bacteria named Pseudomonas aeruginosa, responsible for 90% of the cases. It’s crucial to diagnose this early because it has a high risk of death. So, it should be suspected in people with diabetes or a weak immune system who have an ear infection and a fever that isn’t improving with treatment. Typical treatment includes antibiotics that target the Pseudomonas aeruginosa bacteria. This severe infection can result in infection of the bone behind the ear and paralysis of the facial nerve (the most common nerve affected). NOE can also lead to serious complications like meningitis, dural sinus thrombosis, and cranial abscess.
Preventing Otitis Externa (Swimmer’s Ear)
Telling patients the right way to use ear drops and sticking to the treatment plan is crucial. To do this, the patient should lie down with the side of the affected ear facing up. Then, they should put in two to five drops of the medicine (based on what the doctor has prescribed) and stay in this position for around 3 to 5 minutes. This method will make the treatment work best. Patients should also be cautioned to stay away from water and avoid fiddling with or injuring their ear.
