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External Otitis (Acute)

(Swimmer's Ear)

By

Bradley W. Kesser

, MD, University of Virginia School of Medicine

Reviewed/Revised Feb 2024
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Topic Resources

External otitis is an acute infection of the ear canal skin typically caused by bacteria; Pseudomonas is most common. Symptoms include pain, discharge, and hearing loss if the ear canal has swollen shut; manipulation of the auricle causes pain. Diagnosis is based on history and inspection. Treatment is with careful debridement of dead skin and wax, topical medications (including antibiotics, corticosteroids, and acetic acid or a combination), and dry ear precautions.

External otitis may manifest as a localized furuncle or as a diffuse infection of the entire canal (acute diffuse external otitis). The latter is often called swimmer’s ear; the combination of water in the canal and use of cotton swabs is the major risk factor. Malignant external otitis Malignant External Otitis Malignant external otitis is typically a Pseudomonas osteomyelitis of the temporal bone. Methicillin-resistant Staphylococcus aureus (MRSA) can also cause malignant external otitis... read more is a severe (usually due to Pseudomonas) osteomyelitis Osteomyelitis Osteomyelitis is inflammation and destruction of bone caused by bacteria, mycobacteria, or fungi. Common symptoms are localized bone pain and tenderness with constitutional symptoms (in acute... read more Osteomyelitis of the temporal bone, usually affecting older adults, patients with diabetes, and immunocompromised patients.

Etiology of Acute External Otitis

Acute diffuse external otitis is usually caused by bacteria, such as Pseudomonas aeruginosa, Proteus vulgaris, Staphylococcus aureus, or Escherichia coli. Fungal external otitis (otomycosis), typically caused by Aspergillus niger or Candida albicans, is less common. Furuncles usually are caused by S. aureus and by methicillin-resistant S. aureus (MRSA).

Predisposing conditions include

Attempts to clean the ear canal with cotton swabs can cause microabrasions of the delicate skin of the ear canal (these microabrasions act as portals of entry for bacteria) and may push debris and cerumen deeper into the canal. These accumulated substances tend to trap water, resulting in skin maceration that sets the stage for bacterial infection.

Symptoms and Signs of Acute External Otitis

Patients with external otitis have pain and drainage. If the canal becomes swollen or filled with purulent debris, patients sometimes have a foul-smelling discharge and hearing loss. Exquisite tenderness accompanies traction of the pinna or pressure over the tragus. Otoscopic examination is painful and difficult to conduct. The ear canal appears erythematous, swollen, and littered with moist, purulent debris and desquamated epithelium.

Otomycosis is more pruritic than painful, and patients also report aural fullness. Otomycosis caused by A. niger usually manifests with grayish black or yellow dots (fungal conidiophores) surrounded by a cottonlike material (fungal hyphae). In patients with infection caused by C. albicans, fungi are not visible, but usually, there is a thickened, creamy white exudate, which can be accompanied by spores that have a velvety appearance.

Diagnosis of Acute External Otitis

  • Clinical evaluation

Diagnosis of external otitis is based on inspection. When discharge is copious, external otitis can be difficult to differentiate from an acute, purulent otitis media Otitis Media (Acute) Acute otitis media is a bacterial or viral infection of the middle ear, usually accompanying an upper respiratory infection. Symptoms include otalgia, often with systemic symptoms (eg, fever... read more Otitis Media (Acute) with tympanic membrane perforation; pain elicited by pulling on the pinna may indicate an external otitis. Fungal infection is diagnosed by appearance or culture.

Treatment of Acute External Otitis

  • Debridement

  • Topical acetic acid and corticosteroids

  • Sometimes topical antibiotics

In mild or moderate acute external otitis, topical antibiotics and corticosteroids are effective. First, the infected debris should be gently and thoroughly removed from the canal with suction or dry cotton swabs under adequate lighting. Water irrigation of the canal is contraindicated.

Mild external otitis can be treated by altering the ear canal’s pH with 2% acetic acid (or white vinegar) and by relieving inflammation with topical hydrocortisone; these are given as 5 drops 3 times a day for 7 days.

Moderate external otitis requires the addition of an antibacterial solution or suspension, such as ciprofloxacin or ofloxacin. Neomycin/polymyxin is no longer recommended because the neomycin component is highly sensitizing and often causes an allergic reaction. When inflammation of the ear canal is relatively severe, an ear wick should be placed into the ear canal and wetted with Burow solution (5% aluminum acetate) or a topical antibiotic 4 times a day. The wick helps direct the drops deeper into the external canal when the canal is greatly swollen. The wick is left in place for 24 to 72 hours (or may fall out on its own); after this time, the swelling may have receded enough to allow drops to be instilled directly into the canal.

Severe external otitis or the presence of cellulitis Cellulitis Cellulitis is acute bacterial infection of the skin and subcutaneous tissue most often caused by streptococci or staphylococci. Symptoms and signs are pain, warmth, rapidly spreading erythema... read more Cellulitis extending beyond the ear canal may require systemic antibiotics, such as cephalexin 500 mg orally 4 times a day for 10 days or ciprofloxacin 500 mg orally 2 times a day for 10 days. Whether to use cephalexin or ciprofloxacin can be based on culture and sensitivity. Quinolone antibiotics are not recommended for children because tendon and cartilage damage is a risk (1 Treatment reference External otitis is an acute infection of the ear canal skin typically caused by bacteria; Pseudomonas is most common. Symptoms include pain, discharge, and hearing loss if the ear canal... read more Treatment reference ). An analgesic, such as a nonsteroidal anti-inflammatory drug or even an oral opioid, may be necessary for the first 24 to 48 hours.

Fungal external otitis requires thorough cleaning of the ear canal and application of an antimycotic solution (eg, gentian violet, cresylate acetate, nystatin, clotrimazole, or even a combination of acetic acid and isopropyl alcohol). However, these solutions should not be used if the tympanic membrane is perforated because they can cause severe pain or damage the inner ear. Repeated cleanings and treatments may be needed to fully eradicate the infection.

Dry ear precautions (eg, wearing shower cap, avoiding swimming) are strongly advised for both external otitis and fungal external otitis. A blow dryer on a low setting can also be used to reduce the humidity and moisture in the canal.

A furuncle, if obviously pointing, should be incised and drained. However, if the patient is seen at an early stage, incision is of little value. Topical antibiotics are ineffective; oral antistaphylococcal antibiotics should be given. Analgesics may be necessary for pain relief. Dry heat can also lessen pain and hasten resolution.

Pearls & Pitfalls

  • Applying a few drops of a 1:1 mixture of rubbing alcohol and white vinegar (as long as the eardrum is intact) immediately after swimming can help prevent swimmer's ear (and is also an excellent treatment for otomycosis).

Treatment reference

  • 1. Jackson MA, Schutze GE: The use of systemic and topical fluoroquinolones. Pediatrics 138 (5):e20162706 2016. doi: 10.1542/peds.2016-2706

Prevention of Acute External Otitis

External otitis often can be prevented by applying a few drops of a 1:1 mixture of rubbing alcohol and white vinegar or acetic acid drops (as long as the eardrum is intact) immediately after swimming. The alcohol helps remove (evaporate) water, and the vinegar alters the pH of the canal. Use of cotton swabs or other implements in the canal should be strongly discouraged.

Key Points

  • Acute external otitis is usually bacterial (pseudomonal); fungal infections are less common and cause more itching and less pain.

  • Severe pain when the pinna is pulled suggests acute external otitis.

  • Under close and direct visualization, gently remove infected debris from the canal with suction or dry cotton swabs.

  • Do not irrigate the ear.

  • For mild cases, apply acetic acid and hydrocortisone drops.

  • For moderate or severe cases, debridement and topical antibiotics (use a wick if the canal is swollen) are critical; sometimes give systemic antibiotics.

More Information

The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.

Hajioff D, MacKeith S: Otitis externa. BMJ Clin Evid 0510, 2015.

Drugs Mentioned In This Article

Drug Name Select Trade
Acetasol, Borofair, VoSoL
A-Hydrocort, Ala-Cort, Ala-Scalp, Alkindi, Anucort-HC, Anumed-HC, Anusol HC, Aquaphor Children's Itch Relief, Aquaphor Itch Relief, Balneol for Her, Caldecort , Cetacort, Colocort , Cortaid, Cortaid Advanced, Cortaid Intensive Therapy, Cortaid Sensitive Skin, CortAlo, Cortef, Cortenema, Corticaine, Corticool, Cortifoam, Cortizone-10, Cortizone-10 Cooling Relief, Cortizone-10 External Itch Relief, Cortizone-10 Intensive Healing, Cortizone-10 Plus, Cortizone-10 Quick Shot, Cortizone-5 , Dermarest Dricort, Dermarest Eczema, Dermarest Itch Relief, Encort, First - Hydrocortisone, Gly-Cort , GRx HiCort, Hemmorex-HC, Hemorrhoidal-HC, Hemril , Hycort, Hydro Skin, Hydrocortisone in Absorbase, Hydrocortone, Hydroskin , Hydroxym, Hytone, Instacort, Lacticare HC, Locoid, Locoid Lipocream, MiCort-HC , Monistat Complete Care Instant Itch Relief Cream, Neosporin Eczema, NuCort , Nutracort, NuZon, Pandel, Penecort, Preparation H Hydrocortisone, Proctocort, Proctocream-HC, Procto-Kit, Procto-Med HC , Procto-Pak, Proctosert HC , Proctosol-HC, Proctozone-HC, Rectacort HC, Rectasol-HC, Rederm, Sarnol-HC, Scalacort, Scalpicin Anti-Itch, Solu-Cortef, Texacort, Tucks HC, Vagisil Anti-Itch, Walgreens Intensive Healing, Westcort
Cetraxal , Ciloxan, Cipro, Cipro XR, OTIPRIO, Proquin XR
Floxin, Ocuflox
Neo-Fradin
No brand name available
Biocef, Daxbia , Keflex, Keftab, Panixine
No brand name available
Bio-Statin , KLAYESTA, Mycostatin, Nyamyc, Nyata, Nystex, Nystop, Pedi-Dri
Alevazol , Antifungal, Anti-Fungal, ATHLETE'S FOOT, Cruex, Desenex, Fungoid, Gyne-Lotrimin, Lotrimin, Lotrimin AF, Lotrimin AF Ringworm, Micotrin AC, Mycelex, Mycelex Troche, Mycozyl AC
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NOTE: This is the Professional Version. CONSUMERS: View Consumer Version
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