Otitis Externa (Swimmer's Ear)

How swimmer's ear develops

The ear canal is lined with skin and a protective layer of wax that repels water and is slightly acidic. When water stays in the canal, or the skin is scratched, this barrier breaks down. Bacteria, most often Pseudomonas aeruginosa and Staphylococcus aureus, then multiply. Fungi such as Aspergillus and Candida cause about 1 in 10 cases, particularly after long antibiotic drop use or in hot, humid climates. See fungal ear infection.

Risk factors

• swimming, especially in lakes or poorly treated pools
• frequent showering or living in humid climates
• cleaning ears with cotton swabs, fingers, hairpins or keys
• earbuds, earplugs and hearing aids that trap moisture or scratch
• narrow or hairy ear canals
• eczema, psoriasis or seborrheic dermatitis in the ear
• allergic reactions to hair products, earrings or ear drops (contact dermatitis)
• removing all protective earwax

Symptoms

Mild

• itching inside the ear
• slight redness
• mild discomfort, worse when pulling the outer ear

Moderate

• increasing pain
• clear, yellow or pus-like discharge
• swelling of the canal and a blocked feeling
• muffled hearing

Severe

• intense pain spreading to the face, neck or side of the head
• canal completely swollen shut
• swollen glands in front of or behind the ear
• fever

Swimmer's ear vs middle ear infection

Diagnosis

A clinician looks into the ear with an otoscope and gently moves the outer ear. The canal is red, swollen and may contain debris. If the eardrum is visible, they check it for holes. A swab may be taken for recurrent, severe or fungal infections.

Treatment

Ear drops

• Antibiotic drops, often combined with a steroid to reduce swelling, for 7 to 10 days. Quinolone drops are used if the eardrum might be perforated.
• Antiseptic or acidifying drops for mild cases.
• Antifungal drops for fungal infections.

How to use them: lie with the affected ear up, fill the canal with drops, gently push the flap in front of the ear to help them in, and stay lying for 3 to 5 minutes.

Cleaning and wicks

A clinician may gently clean debris from the canal so drops reach the skin. If the canal is very swollen, a small sponge wick is placed to carry the drops inside; it is removed or falls out within a few days.

Pain relief

Acetaminophen (paracetamol) or ibuprofen at the label dose. Pain usually improves within 1 to 3 days of starting drops.

Oral antibiotics

Usually not needed. They are used if infection spreads beyond the ear canal, in people with diabetes or weakened immunity, or when drops cannot be given.

During treatment

• Keep the ear dry: use a cotton ball coated with petroleum jelly in the ear when showering.
• Avoid swimming for 7 to 10 days, or as advised.
• Do not use earbuds, hearing aids or earplugs until pain and discharge settle.

Malignant (necrotizing) otitis externa

A rare but serious infection that spreads from the ear canal into the skull base bone, mainly in older adults with diabetes or weakened immunity. Symptoms are severe, persistent ear pain often worse at night, discharge, and sometimes facial weakness. It needs urgent specialist treatment with long courses of antibiotics. See malignant otitis externa.

Prevention

• Dry ears after swimming and showering: tilt the head, pull the earlobe in different directions, and use a hair dryer on the lowest setting held at arm's length.
• Wear a swim cap or well-fitting earplugs.
• Do not put cotton swabs or objects in the ear canal.
• Leave earwax alone unless it causes a blockage.
• Over-the-counter acidifying drying drops after swimming can help people prone to swimmer's ear, but do not use them if you have ear tubes, a perforated eardrum or current infection.
• Clean earbuds and hearing aids regularly.

Frequently asked questions

How do I know if I have swimmer's ear?

Swimmer's ear typically causes ear pain that worsens when you pull on the earlobe or press the flap in front of the ear, along with itching, redness, discharge and muffled hearing, often after swimming. A clinician can confirm it by looking into the ear.

How long does swimmer's ear last?

With antibiotic ear drops, pain usually improves within 1 to 3 days and the infection clears within 7 to 10 days. Keep the ear dry during treatment. See a doctor if it has not improved after 3 days or is not gone within 2 weeks.

Can swimmer's ear go away on its own?

Very mild cases with only itching may settle if the ear is kept dry, but most painful infections need ear drops. Untreated swimmer's ear can worsen and spread to surrounding skin and, rarely, bone.

Is swimmer's ear contagious?

No. Swimmer's ear is not spread from person to person. It develops when moisture or skin damage lets bacteria or fungi grow in the ear canal. Sharing earbuds or earplugs is still best avoided.