Acute Otitis Externa (Swimmer’s Ear)

Otitis externa is inflammation and infection of the external auditory canal. The most common organisms are staphyloccus aureus and pseudomonas aeruginosa. Less common organisms include proteus species, staphyloccus epidermidis, diptheroids, and E. Coli.

There Are Two Stages:

  • Preinflammatory stage- the ear is exposed to heat, humidity, absence of cerumen, an alkaline PH.
  • Inflammatory stage-bacterial overgrowth with increased edema and pain.

How Do I Know if I Have Otitis Externa?

Patients will often experience ear pain, drainage, ear fullness, tenderness, ear canal occlusion, and history of water exposure. The occlusion of the ear canal may lead to hearing loss. Some patients may experience discharge from ear which can be purulent and foul smelling.

Examination reveals swelling, redness, narrowing of the ear canal, and discharge. In severe cases, patients may experience cellulitis (infection) of the face or neck.

In addition, patients may experience a fungal overgrowth in the ear canal. Fungal otitis externa can cause severe itching with thick white discharge. Patients with fungal otitis externa typically complain of less pain than patients with bacterial otitis externa, though this infection can cause significant damage to the eardrum.

Foreign objects in children’s ears must also be considered. A foreign object may cause pain and purulent discharge; their symptoms will not improve unless the foreign of object is removed.

Potential Complications:

Complications are rare, but may include: cellulitis (infection of the skin), mastoiditis, chondritis of the auricle (spread of infection to the cartilage of the outer ear), osteomyelitis (infection of the bone), and necrotizing otitis externa. 
Necrotizing otitis externa is when the infection extends to the temporal bone and is more commonly seen in diabetic elderly patients or those that are immunocompromised. At times, the cranial nerves can be affected because of the inflammation around the nerves. In addition, patients will complain of marked tenderness and granulation tissue may be present on examination.


Otitis externa is diagnosed based on clinical history and physical examination. Therefore, labs or imaging are usually not needed. It may be necessary to obtain a culture of the discharge from the auditory canal if fungal component is suspected or if ear is not responding to therapy.

CT scan is generally not warranted unless invasive infection is suspected. A CT scan may be performed to assess whether the bone is involved with infection.


Treatment of otitis externa is management of pain, clearing debris from the auditory canal, and placing otic medications (ear drops) to resolve swelling and infection. Removal of any debris in the ear canal with a microscope is often necessary to improve the effectiveness of the otic medications and to allow for a quicker recovery. The antibiotic drops are dosed for 7 days and it is imperative that patient avoid swimming or manipulation of the ear canal. In addition, oral antibiotics are often required depending on the severity of the disease.

Fluoroquinolones are safe antibiotic otic drops and are not associated with ototoxicity and can be administered in ear with a tympanic membrane perforation. Other antibiotic preparations can include neomycin, polymyxin, gentamicin, and tobramycin. If the external auditory canal is too edematous for effective administration of otic drops, the provider may insert a wick into ear canal to help deliver the medication.

For fungal infections, the provider will administer antifungal agents that may include gentian violet and other specific antifungals. These are only administered after the ear canal is cleared of all debris.

During treatment, the patient will be advised to keep the ear canal dry while showering by placing a cotton ball in the affected ear. Patients who are involved in aquatic activities and sports may return to water within 4-5 days after resolution of infection. Return to activities is patient dependent and provider should clear the individual prior to resumption.

Oral antibiotics are used in patients with associated fever, swollen lymph nodes, diabetes, or evidence of progressive infection extending to face or neck. IV antibiotics are given to patients with necrotizing otitis externa or severe cellulits.

How Can I Prevent Otitis Externa?

Some patients may experience recurrent symptoms and need good ear hygiene practices and prophylactic treatments. It is important to manage good ear hygiene by:

  • Avoid potential traumas to ear canal by avoiding q-tips, bobby pins, etc.
  • Avoid excessive washing of ears with soap
  • Avoid swimming in contaminated water. 
  • Keeping ear dry by holding a hair dryer to ear after showering or swimming
  • Patients can also instill prophylactic drops in ear to keep dry after exposure to water. The drops are a combination of acetic acid and isopropyl alcohol. 
  • Earplugs may be effective, but is generally not recommended because of risk of trauma to ear canal and person must clean earplugs after each use.