Summer has arrived so let’s talk about “swimmer’s ear.” Also known as Otitis
Externa, we’ve discussed this previously but did not elaborate a whole
lot on the symptoms and treatment. So
here it is. Sometimes otitis externa is
not treated appropriately and many times patients are not aware of the
precipitating factors that cause this not-too-uncommon problem.
First of all, we must distinguish between the two major types
of ear infections. Patients who present
to me with the complaint of recurrent ear infections often simply state, “I get
a lot of ear infections.” What do they
mean exactly? I try to drill down on
this, often asking, “Do you recall if your doctor said you had otitis media or otitis
externa? Or did they mention if you had
an inner versus an outer ear infection?”
I explain this distinction determines proper treatment, as the treatment
for one is entirely different than the other.
Otitis
Media is an infection localized behind the ear drum, in the
space known as the middle ear.
Though some lay people refer to this as an “inner ear infection,” this
is not entirely correct, for the “inner ear” refers to the cochlea deep to the
middle ear space; hence the “media” in the term otitis media. An “outer ear infection,” is more appropriately
termed, and thus the more official term of otitis externa. Otitis externa includes the tissues lateral
to (or outward from) the tympanic membrane (ear drum). In both otitis externa and otitis media, the
tympanic membrane also can become infected or inflamed but less often in otitis
externa.
The causes of each are different as well. In otitis media, one often has a prior cold
or upper respiratory infection, or has experienced sudden changes in
atmospheric pressure such as an air-flight.
This impairs opening of the eustachian tube which in turn causes changes
in the middle ear, leading to inflammation, trapped fluid and ultimately an
infection. In otitis externa however,
the cause is external to the ear drum, such as trauma to the ear canal or retained
water or perspiration. Hence it is often
called “swimmer’s ear,” though oftentimes the patient hadn’t previously swam,
but the infection is the same despite the cause. Sometimes impacted ear wax can trigger otitis
externa especially if it traps water behind the impaction or if the wax is dry
and irritating the ear canal skin.
The signs and symptoms of otitis externa:
1. Ear pain, often
quite severe.
2. Swelling of the
ear canal and sometimes of the auricle itself (the outer most part of the ear). Swelling can also extend the backside of the
ear, sometimes giving the false impression of mastoiditis (infection of mastoid
bone located behind the auricle).
3. Ear drainage is
sometimes noted.
4. Decreased hearing
if the ear canal is more severely swollen or if soft tissue or drainage is
trapped.
5. Pain and swelling
in front of the ear, namely in the area of the temporal
mandibular joint. This can then
lead to,
6. Difficulty chewing
or opening and closing the mouth. Some
patients may also notice malocclusion, where the teeth do not meet correctly,
due to a shift in the mandible (lower jaw) due to swelling in the TMJ area.
7. Enlarged lymph
nodes around the ear or in the upper neck.
Otitis externa is typically caused by a bacterium called Pseudomonas
aeruginosa. Treatment centers on
eradicating this particular organism.
Cultures often are not needed (unless the patient is not responding to treatment
as below). The bacteria causing most
case of otitis media are entirely different (Streptococcus pneumonia, Haemophilus
influenzae, and Moraxella catarrhalis are the three common bacteria
in otitis media). Oral antibiotics are
required for otitis media; the antibiotic must be absorbed into the blood
stream to deliver itself to the target tissue of the middle ear space which
cannot be accessed by external means (unless there is a hole or an artificial
tube across the eardrum). However,
otitis externa responds requires a topical (placed directly onto the involved
tissue) antibiotic, often combined with a steroid, placed directly into the ear
via the ear canal.
Treatment for otitis externa:
1. Keep the ear
completely dry. Avoid water in the ear. This can be accomplished by a cotton ball
placed in the ear and then a layer of Vaseline over the outer part of the
cotton ball during bathing or showering.
Also, avoid swimming or hot tubs (steam and moisture from the latter
could enter the ear and aggravate the infection).
2. Topical antibiotic
ear drops, often combined with a steroid.
The antibiotic goes directly onto the target to kill bacteria and the
steroid helps to reduce inflammation and swelling to hasten resolution of the
infection. Cortisporin suspension
(neomycin, polymyxin, hydrocortisone) is often used and works quite well. If a perforation in the tympanic membrane is
suspected, Ciprodex (ciprofloxacin with dexamethasone—a steroid) or ofloxacin drops
are often used, since these do not have the potential for ototoxicity to the
cochlea (which can result in hearing loss due to damage to the cochlea) as
neomycin might.
3. Oral antibiotics are
often not needed, unless there are swollen lymph nodes (in front of the ear but
also can occur behind and below the ear or in the upper part of the neck) or if
there is cellulitis (infection of soft tissues such as skin) of the
auricle and skin around the auricle.
Rarely, patients need to be admitted for i.v. antibiotics, unless they
have other comorbidities such as uncontrolled diabetes, severe cellulitis or potential
sepsis (i.e. infection spreading through the blood stream).
4. If swelling is
more severe, an expandable wick can be placed directly into the ear canal. This is a compressed sponge that when
activated by fluid, expands to about 5x its original size. This sponge pushes out the edema of the canal
tissues and allows the medicated ear drops to get deeper into the ear canal and
to the target tissues. Also, since the
sponge absorbs the ear drops, it allows for a more continues contact of the
medication to the infected tissue. Warning:
placement of the wick can hurt like hell, but the pain eventually subsides once
it is expanded and soften with the drops.
Once the swelling resolved, the wick can fall out on its own, but often
the doctor needs to remove it, usually around a week later.
5. Narcotic pain
medication may be required. We typically
have patients use this as a last resort, trying first over-the-counter (OTC)
medications such as acetaminophen or ibuprofen.
As they say, an ounce of prevention is worth a pound of
cure. The key is to avoid irritating or
traumatizing the ear. Any slight
disruption of the skin of the ear canal can lead to otitis externa. Keep the ear dry during swimming or showering
with silicone or plastic ear plugs or even a swim cap or waterproof head band
that covers the ears. Avoid cleaning the ears with instruments such
as cotton swabs (Q-tips), paper clips, bobby pins or the like. Doing such things can easily traumatize the
ear causing big-time problems (see Ear
Cleaning: Do’s and Don’ts). You can also
prevent otitis externa by filling the ear canal isopropyl alcohol (i.e.,
“rubbing alcohol,” available at most stores; don’t use the good stuff such as
your expensive bottle of Tequila—save that for your summertime margaritas) after
swimming or bathing serves two purposes:
(1) Alcohol has a lower evaporation temperature with water, dissolves
easily in water and thus serves to remove residual water, and (2) it kills
bacteria. I have mothers and fathers of
young children who carry a small dropper bottle of alcohol in their handbags or
gym bags whenever they take the kids out swimming. If you can’t find a dropper, use a cotton ball
as a makeshift dropper by soaking it with alcohol and then squeezing it to
release the alcohol in the ear. Massage
the alcohol in the ear by gently pumping on the tragus (the flap of tissue that
partially covers the entrance to the canal and is attached in front of
it). Then tilt the head to allow the
alcohol to drain out of the ear. Simple
as that, nothing fancy.
So enjoy your summer, stay safe, and hope not to see you in
the clinic or E.R. with terrible ear pain.
©Randall S. Fong, M.D.
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