Prevention and Treatment of Swimmer’s Ear

Full update July 2020

Swimmer’s ear (also called acute otitis externa) is a diffuse inflammation of the external ear canal.1-3 Inflammation can extend to the external ear or inward to the tympanic membrane.2,3 Swimmer’s ear is associated with prolonged contact of water in the ear canal.4 This moist environment can lead to breaks in the skin, providing an entry for microorganisms.3,4 Acute otitis externa can also be caused by disruption to the ear canal caused by eczema, hearing aids, ear phones, etc. The most common pathogens are Pseudomonas aeruginosa and Staphylococcus aureus, and infections are often polymicrobial.2,3 Fungal involvement (e.g., Aspergillus, Candida) is uncommon but may be seen in chronic otitis externa or sometimes after treatment with topical or systemic antibiotics.2,3 Symptoms include ear pain, tenderness, swelling, redness, and discharge in the ear canal.2,3,5 Typically only one ear is affected.2 The following chart includes strategies to prevent and treat swimmer’s ear; including choices for perforated tympanic membrane (e.g., ruptured ear drum, tympanostomy tubes, etc), other therapeutic considerations, and cost.

Abbreviations: BID = twice daily; NNT = number needed to treat; NSAID = nonsteroidal anti-inflammatory drug; OTC = over the counter; QID = four times daily; TID = three times daily.

Prevention: Strategies focus on protecting the ear canal and keeping it dry.


  • Avoid swimming in water that has high bacterial levels.6 Check local information on bacteria counts in your lakes and beaches prior to swimming.
  • Do not clean or scratch the inside of the ear canal with cotton swabs, your fingernail, or other objects.
  • Keep soap and bubble bath out of the ear canal to avoid possible irritation.
  • Patients should generally leave earwax alone as it is considered protective. If earwax is obstructive, it may be removed by their prescriber.3
  • Ear candling is NOT recommended for preventing/treating swimmer’s ear, or for cleaning. It is considered ineffective and potentially dangerous.17

Keep the ear canal dry before, during, and after water exposure (e.g., swimming, showering):1,2,7

  • Use earplugs while swimming.
  • Dry the ears after swimming or showering with a hair dryer on the lowest setting, held several inches from the ear.
  • Tilt the head to remove water from the ear canal.
  • Various otic solutions may be used prior to and after water exposure to acidify the ear canal and/or to help dry out the ears. Do NOT use these solutions in patients who have ear tubes, damaged or ruptured ear drums, or discharge from the ears.1 These otic solutions include:
    • OTC isopropyl alcohol drops (Swim-Ear, Auro-Dri Ear, etc).
    • One part white vinegar plus one part isopropyl alcohol. Put 5 mL into each ear, then allow to drain out.6
    • One part white vinegar plus one part water. Put 5 mL into each ear, then allow to drain out.8
    • Prescription acetic acid otic solution (U.S. only) (VoSol, generics).
    • Aluminum acetate, Burow’s solution (Domeboro, Buro-Sol, etc), four to six drops into each ear after swimming.9


Treatment: Use topical anti-infectivesa,b as initial therapy for uncomplicated swimmer’s ear.3 Topical agents are preferred over systemic antibiotics as they deliver higher concentrations at the site of the infection.d

Consider cost and convenience when selecting an agent. Ophthalmic formulations can generally be used in the ear and are sometimes less expensive compared to otic drops.10

There is no good evidence that one topical anti-infective (excluding clioquinol) works better than another (NNT = 2 patients for 1 cure) [Evidence Level B-2].3

Treatment duration is generally seven to ten days.2-4,7 Clinical response should be seen within 48 to 72 hours.3,4 Lack of symptom resolution by day 14 should be considered a treatment failure.7

The addition of a corticosteroid (in combination drops) might result in faster resolution of ear pain by about one day [Evidence Level B-1].12

When access to the ear canal is reduced due to inflammation, a wick can be placed in the ear to increase the amount of medication that reaches the inner part of the ear canal and to increase contact time with the anti-infective.13

Swimming should be avoided during treatment (about a week). Competitive swimmers can sometimes return sooner (in two to three days), if pain has resolved and well-fitting earplugs are used.3

During treatment, cotton balls with petrolatum or earplugs can be used in the affected ear(s) while showering or other exposure to water.

After administering drops, the patient should remain on their side for three to five minutes.3



Topical Anti-Infective

Therapeutic Considerations

Dosing and Costc

Acetic acid 2% otic solution (U.S. only)
VoSol [brand no longer available], generics)

Acetic acid 2% with hydrocortisone 1% otic solution (U.S. only)
(VoSol HC [brand not available], generics)


Avoid in patients who do not have an intact tympanic membrane (including those with tympanostomy tubes) because of potential ototoxicity and pain.3,4

May consider using 1:1 white vinegar:water (or isopropyl alcohol) in place of commercial product.6,8

May be effective for mild disease and inflammation.13

Dosing frequency: every 4 to 6 hours7

Cost:

  • acetic acid: $28/15 mL
  • acetic acid/hydrocortisone:
    ~$148/10 mL

Ciprofloxacin 0.2% otic solution
(U.S. only) (Cetraxal, generics)

Ciprofloxacin 0.3% ophthalmic solution
(Ciloxan, generics)

Ciprofloxacin 6% otic suspension
(U.S. only) (Otiprio)

Ciprofloxacin 0.3% with
Dexamethasone 0.1% otic suspension
(Ciprodex)

Ciprofloxacin 0.2% with
Hydrocortisone 0.1% otic suspension (U.S. only)(Cipro HC)


Consider in patients who do not have an intact tympanic membrane (e.g., tympanostomy tubes, ruptured eardrum, etc) because the formulation is not ototoxic.3,5,7 However, avoid any non-sterile formulations (e.g., Cipro HC) in these patients.14

Ciprofloxacin 6% otic suspension [U.S. only] is given as a single dose of 12 mg (0.2 mL) into each affected ear.9


Dosing frequency: BID3 (except 6% suspension)

Cost:

  • Otic 0.2% soln: $100/14 doses (U.S.)
  • Ophthalmic:
    • ~$20/5 mL (U.S.)
    • $10/5 mL (Canada)
  • Otiprio: $283/1 mL (U.S.)
  • Ciprodex:
    • $249/7.5 mL (U.S.)
    • $31/7.5 mL (Canada)
  • Cipro HC: $316/10 mL (U.S.)

Clioquinol 1%, flumethasone 0.02% otic drops (Canada only)
(Locarten Vioform)

Clioquinol is bacteriostatic vs fungi (e.g., Candida) and gram-positive organisms (e.g., Staphylococci), with only slight inhibitory effect on gram-negative bacteria.15

Avoid in patients who do not have an intact tympanic membrane.15


Dosing frequency: BID15

Cost:

  • $23/11 mL (Canada)

Framycetin 5 mg/mL, Gramicidin 0.05 mg/mL, Dexamethasone 0.5 mg/mL ophthalmic/otic solution (Canada only)
(Sofracort)


Avoid in patients who do not have an intact tympanic membrane (including those with tympanostomy tubes) because of potential ototoxicity.16

Dosing frequency: TID to QID16

Cost:

  • $18/8 mL (Canada)

Gramicidin 0.025 mg/mL, Polymyxin B 10,000 units/mL
ophthalmic/otic solution (Canada only)
(Optimyxin, Polysporin Eye/Ear)

Avoid in patients who do not have an intact tympanic membrane (including those with tympanostomy tubes) because of potential ototoxicity.4

A formulation of polymyxin B plus lidocaine is also available (Polysporin Plus Pain Relief Ear drops).


Dosing frequency: QID4

Cost:

  • Optimyxin: $12/10 mL (Canada)
  • Polysporin: $12/15 mL (Canada)

Neomycin 0.35%, Polymyxin B 10,000 units/mL, Hydrocortisone 1%
(U.S. only)
otic suspension (Aural, Oticin HC, generics)
otic solution (Cortisporin, Oticin HC, generics)

Avoid in patients who do not have an intact tympanic membrane (including those with tympanostomy tubes) because of potential ototoxicity.3,4,7

Suspension may be less irritating than solution due to higher pH.10

Neomycin-containing otics may cause contact hypersensitivity (up to 1 in 3 patients).3

Note that other aminoglycosides (e.g., ophthalmic gentamicin, tobramycin) are also sometimes considered due to their (typically) lower cost.


Dosing frequency: TID to QID3,4,7

Cost:

  • Solution or suspension: $84/10 mL (U.S.)

Ofloxacin 0.3%
otic solution (U.S. only) (generics)
ophthalmic solution (Ocuflox, generics in U.S. only)

Consider in patients who do not have an intact tympanic membrane (including those with tympanostomy tubes) because the formulation is not ototoxic.3,4,7

Dosing frequency: once daily to BID3,7

Cost:

  • Otic: ~$68/5 mL (U.S.)
  • Ophthalmic:
    • ~$30/5 mL (U.S.)
    • $15/5 mL (Canada)


Symptomatic Management

Analgesic

Therapeutic Considerations

Oral acetaminophen or NSAID
(e.g., ibuprofen)

Add to anti-infectives for patients with ear pain.3

Acetaminophen or an NSAID in combination with an opioid may also be used if necessary.3

Typical duration of the analgesic should be 48 to 72 hours.3

When frequent dosing is required to better control severe pain, schedule doses rather than using analgesics as needed.2


Topical analgesics, natural products
(e.g., benzocaine [Auralgan, Canada only], lidocaine, Ear Oil, Hyland’s Earache drops [homeopathic], sweet oil)

Discourage the use of topical analgesic drops.

Topical analgesics may mask progression of underlying disease, compromise the efficacy of otic antibiotics, and cause dermatitis.2,3,7

Natural product earache drops (e.g., Ear Oil, Hyland’s) and sweet oil are unlikely to help.11

Always avoid use in patients without an intact tympanic membrane, including those with tympanostomy tubes.2,3,7



  1. The most commonly used treatments are listed, and may not be all-inclusive.
  2. Some ophthalmic antibiotics only available in Canada are listed due to the limited selection of otic anti-infective products in Canada.
  3. Cost is wholesale acquisition cost (WAC) of the generic product, when available, for a typical treatment course in an adult. U.S. medication pricing by Elsevier, accessed June 2020.
  4. Available evidence does not support the use of oral antibiotics for most patients.3 Their unnecessary use should be avoided due to the increased risk of adverse effects, the development of resistance, and infection recurrence.2,7 Use oral antibiotics that cover S. aureus and P. aeruginosa as initial therapy to supplement topical anti-infectives for patients with diabetes, immunocompromise due to HIV, or a history of radiation to the head; for infections that extend outside the ear canal; or if there is uncertainty that topical therapy can be delivered effectively.3 Individuals who have diabetes or are immunocompromised may have more severe and resistant cases of swimmer’s ear, such as necrotizing (malignant) otitis externa with involvement of bone and soft tissue. Treatment for necrotizing otitis externa involves systemic antibiotics plus surgical debridement.7


Levels of Evidence

In accordance with our goal of providing Evidence-Based information, we are citing the LEVEL OF EVIDENCE for the clinical recommendations we publish.

Level

Definition

Study Quality

A

Good-quality patient-oriented evidence.*

  1. High-quality RCT
  2. SR/Meta-analysis of RCTs with consistent findings
  3. All-or-none study

B

Inconsistent or limited-quality patient-oriented evidence.*

  1. Lower-quality RCT
  2. SR/Meta-analysis with low-quality clinical trials or of studies with inconsistent findings
  3. Cohort study
  4. Case control study

C

Consensus; usual practice; expert opinion; disease-oriented evidence (e.g., physiologic or surrogate endpoints); case series for studies of diagnosis, treatment, prevention, or screening.

*Outcomes that matter to patients (e.g., morbidity, mortality, symptom improvement, quality of life).

RCT = randomized controlled trial; SR = systematic review [Adapted from Ebell MH, Siwek J, Weiss BD, et al. Strength of Recommendation Taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician 2004;69:548-56. http://www.aafp.org/afp/2004/0201/p548.pdf.]

Project Leader in preparation of this clinical resource (360703): Annette Murray, BScPharm

References

  1. The Hospital for Sick Children. Swimmer’s ear (otitis externa). May 21, 2014. https://www.aboutkidshealth.ca/article?contentid=747&language=english. (Accessed June 16, 2020).
  2. Schaefer P, Baugh RF. Acute otitis externa: an update. Am Fam Physician 2012;86:1055-61.
  3. Rosenfeld RM, Schwartz SR, Cannon CR, et al. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck Surg 2014;150(Suppl 1):S1-S24.
  4. Hui CP, Canadian Paediatric Society, Infectious Diseases and Immunization Committee. Acute otitis externa. Reaffirmed February 28, 2018. Paediatr Child Health 2013;18:96-8.
  5. McWilliams CJ, Smith CH, Goldman RD. Acute otitis externa in children. Can Fam Physician 2012;58:1222-4.
  6. Mayo Clinic. Swimmer’s ear. https://www.mayoclinic.org/diseases-conditions/swimmers-ear/diagnosis-treatment/drc-20351688. (Accessed June 7, 2020).
  7. Wipperman J. Otitis externa. Prim Care 2014;41:1-9.
  8. Seattle Children’s. Ear – swimmer’s. Reviewed March 22, 2020. https://www.seattlechildrens.org/conditions/a-z/ear-swimmers/. (Accessed June 7, 2020).
  9. Clinical Pharmacology powered by ClinicalKey. Tampa (FL): Elsevier. 2020. http://www.clinicalkey.com. (Accessed June 8, 2020).
  10. Hughes E, Lee JH. Otitis externa. Pediatr Rev 2001;22:191-7.
  11. Jellin, J., Gregory PJ, et al. Natural Medicines. www.naturalmedicines.com. Accessed on June 22, 2020. © 2001-2020 by Therapeutic Research Center. Terms of Use: https://naturalmedicines.therapeuticresearch.com/terms-of-use.aspx.
  12. Pistorius B, Westberry K, Drehobl M, et al. Prospective, randomized, comparative trial of ciprofloxacin otic drops, with or without hydrocortisone otic suspension in the treatment of acute diffuse otitis externa. Infect Dis Clin Pract 1999;8:387-95.
  13. Gogenn LA. External otitis: treatment. Last updated June 14, 2019. In UpToDate, Post TW (Ed.), UpToDate, Waltham, MA.
  14. Product information for Cipro HC. Alcon. Fort Worth, TX 76134. March 2017.
  15. Product monograph for Locacorten Vioform. Paladin Labs. Montreal, QC H4P 2T4. May 2009.
  16. Product monograph for Sofracort. Sanofi-Aventis Canada. Laval, QC H7V 0A3. December 2018.
  17. Schwartz SR, Magit AE, Rosenfeld RM, et al. Clinical practice guideline (Update): earwax (cerumen impaction). Otolaryngol Head Neck Surg 2017;156:s1-29.

Cite this document as follows: Clinical Resource, Prevention and Treatment of Swimmer’s Ear. Pharmacist’s Letter/Prescriber’s Letter. July 2020.

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