Otitis externa is fairly common, especially among teenagers and young adults. Swimming in polluted water is one way to contract swimmer's ear, but it is also possible to contract swimmer's ear by swimming in a pool that is well maintained or even from water trapped in the ear canal after a shower, especially in a humid climate. Water trapped in the ear canal is not the only cause, however -- the condition can be caused by scratching the ear or an object stuck in it. Trying to clean wax from the ear canal, especially with cotton swabs or small objects, can irritate or damage the skin. It is occasionally associated with middle ear infection (otitis media) or upper respiratory infections such as colds. Middle ear infections can occur after the ear drum is perforated by a fungal growth from the outer ear. Moisture in the ear predisposes the ear to infection from fungus or water-loving bacteria such as Pseudomonas.

Symptoms

Ear pain -- may worsen when pulling the outer ear
Itching of the ear or ear canal
Drainage from the ear -- yellow, yellow-green, pus-like, or foul smelling
Decreased hearing or hearing loss

Signs and tests

When the physician looks in the ear, it appears red and swollen, including the ear canal. The ear canal may appear eczema-like, with scaly shedding of skin. Touching or moving the outer ear increases the pain. It may be difficult for the physician to see the eardrum with an otoscope. Taking some of the ear's drainage and doing a culture on it may identify bacteria or fungus.

Treatment

The goal of treatment is to cure the infection. The ear canal should be cleaned of drainage to allow topical medications to work effectively. Depending on how severe the infection is, it may be necessary for a doctor to aspirate the ear as many times as twice a week for the first two or three weeks of treatment.

Effective medications include eardrops containing antibiotics to fight infection, and corticosteroids to reduce itching and inflammation. Use of antibiotics to treat ear infections may result in treatment of the wrong cause of the infection because not all ear infections are bacterial; some are fungal, and it is possible to have both a bacterial and fungal ear infection.

Ear drops should be used abundantly (four or five drops at a time) in order to penetrate the end of the ear canal. If the ear canal is very swollen, a wick may be applied in the ear to allow the drops to travel to the end of the canal. Occasionally, pills may be used in addition to the topical medications. Analgesics may be used if pain is severe. Putting something warm against the ears may reduce pain.

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Swimmer's Ear
From Pediatrics for Parents, 4/1/98 by Richard Moss

"Ouch! My ear hurts, Mom." And it's the middle of summer. Chances are your child is suffering from otitis externa. Known also as "swimmer's ear," otitis externa is an infection of the ear canal. Although this condition can occur throughout the year, it usually arises in the summer because of the higher humidity, increased perspiration, and ... swimming.

The ear canal is the narrow tube-like structure leading to the ear drum. Its main function is to direct sound waves toward the eardrum. To do this, the ear canal must remain open and infection-free. The ear canal accomplishes this in a number of ways: it has a self-cleaning mechanism that prevents keratin (a component of dead cells) shed by the skin of the ear canal from accumulating; it has an acidic environment that inhibits the growth of most pathogenic organisms (i.e., bacteria that can cause problems); and it has cerumen (earwax), which has anti-bacterial properties. Despite these defenses, the ear canal is still prone to developing infection.

The main reason infections occur is that the ear canal, being a narrow tube, retains moisture. The persistent moisture soaks up acid. This changes the acid level in the canal so it's more favorable to the growth of harmful bacteria. The shed keratin in the ear canal absorbs moisture and provides a good culture medium for bacteria. The moisture also softens or macerates the skin.

Children who are most susceptible to developing otitis externa are swimmers (hence the name, "swimmer's ear"), children who live in moist environments, and children who retain water in the canals because of narrowing of the canal or too much earwax stuck in the canal. Hearing aids also encourage the retention of moisture, which increases the likelihood of infection.

Otitis externa can also develop from trauma to the ear canal, usually self-inflicted. Scratching or abrading the ear canal with a Q-tip, a finger, a bobby-pin, etc., is the usual cause.

Otitis externa usually begins with discomfort and itching, followed by tenderness and pain. Children may also complain of fullness and pressure sensation in the ear. In more severe cases, the child may complain of hearing loss due to the swelling and blockage. The infection is usually limited to the ear canal with no systemic findings such as fever or chills. Swimmer's ear doesn't cause middle ear infections. There's not relationship between the two except they are both infections of the ear -- but different parts of the ear.

When the doctor looks into the ear canal of an infected ear it looks red. There may be a small amount of a sticky whitish-gray material. This sticky stuff rarely drains from the ear. In severe cases, the ear canal will swell almost completely shut.

Initial treatment consists of topical otic (ear) drops. A variety of solutions are available, most a combination of antibiotics (usually polymyxin and neomycin) and steroids. Acetic acid drops, with or without steroids, are also frequently used. The dilute acetic acid restores the acidity of the ear canal, which kills Pseudomonas aeruginosa, the bacteria that usually causes the problem. Ophthalmic (eye) drops have become popular in the treatment of otitis externa. Most contain an antibiotic and steroid, often at a higher concentration than the otic drops.

Careful and thorough cleaning of the ear canal by the physician is essential. Removal of debris and infected material will allow the drops to reach the skin directly. When the ear canal is swollen shut, insertion of a wick may be needed. The wick acts like a sponge, drawing the drops deep into the ear canal. Oral antibiotics are usually not needed for the treatment of otitis external except in persistent cases.

For children inclined to repeated episodes, prevention of otitis externa begins with the use of ear plugs when bathing or swimming. Drops containing acetic acid and alcohol (the alcohol helps to dry the ear) are available over-the-counter and may be used routinely after swimming. Gentle drying of the ear canals with a blow dryer after bathing can be helpful. Avoid scratching the ear canals or over vigorous cleaning with Q-tips. Children with hearing aids, who have had repeated episodes of otitis external should consider having the hearing aids vented to improve ventilation of the ear canal.

Dr. Moss is an Ear-Nose-and-Throat specialist practicing in Jasper, IN. Many of his patients are children.

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