Swimmer’s ear a mild but burdensome illness

• Copyright © 2011 by the American Academy of Pediatrics

Acute otitis externa (AOE), known as “swimmer’s ear,” is a common problem encountered in primary care practice, particularly in the summer months. Although AOE generally is a mild illness, it is responsible for a substantial burden in terms of health care dollars and clinicians’ time.

As a conservative estimate, 2.4 million U.S. health care visits result in a diagnosis of AOE annually (8.1 visits/1,000 population), affecting at least one in 123 persons each year. In 2007, one in 324 emergency department visits and one in 481 ambulatory care clinic visits resulted in a diagnosis of AOE. In addition, nonhospitalized visits for AOE cost more than $489 million in direct health care costs.

Although the illness usually is relatively mild, patients might be prevented from attending school, work or social activities. Passing along some simple messages to patients and their families, especially in the spring, can help prevent some cases of AOE.

Causes, symptoms of AOE

AOE is inflammation of the outer ear canal characterized by redness, swelling, pruritus, occasional exudate and pain, particularly when the pinna is moved. The vast majority of AOE is caused by bacteria. The most common include Pseudomonas aeruginosa and Staphylococcus species.

Collier

Factors that predispose the ear to infection include high temperature, high humidity and water exposure, especially swimming. Exposure of the skin of the ear canal to water, particularly when prolonged, can lead to skin maceration, making it more vulnerable to minor trauma and infection. Minor trauma could be caused by anything inserted in the macerated ear canal such as cotton-tip swabs, hearing aids, other foreign objects or even one’s own finger when scratching itchy ears. Water exposure also can wash away protective cerumen, which serves as a water-repellent coating for the skin of the canal and provides antimicrobial properties.

Studies have shown that AOE is more likely to occur among swimmers. The longer swimmers are in the water and the more frequently they submerge their head increase the risk for AOE. Soaps, shampoos and chlorine from pool water might irritate the skin of the external ear canal and also contribute to the loss of protective cerumen.

Dr. Beach

Because AOE is more likely to occur among swimmers and in warm, humid environments, it is not surprising that AOE peaks in the summer months. Also, rates of AOE are higher in the humid Southeast. With increasing use of indoor recreational water facilities, however, AOE may be encountered year-round. AOE is found among patients of all ages; the highest rates occur in children ages 5-9 years.

Treatment

Topical treatment is highly effective for AOE. Topical antimicrobials either alone or in combination with a corticosteroid are superior to placebo. Cure rates are comparable between topical combination drops and topical antimicrobials alone.

Dr. Brady

Instruct patients to use the drops for at least a week, continuing use for a few days after symptoms resolve. Most patients have resolution of symptoms by six days after starting treatment. If no improvement is noted in 48-72 hours, or if symptoms persist beyond two weeks, consider switching to a different medication.

For straightforward cases of AOE that do not involve cellulitis, necrotizing otitis externa or other complicating factors (e.g., diabetes or immunosuppression), there does not appear to be any advantage to administering systemic antimicrobials.

Patients with AOE should avoid submerging their head in water for seven to 10 days, but competitive swimmers might be able to return to the pool if pain has resolved and they use well-fitting ear plugs.