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Otitis Externa: Swimmer's Ear

Oh, I can't believe I haven't written about this before because this little nasty condition plagued my childhood. I remember crying late into the night after a day swimming at my Dad's house, in complete agony, dragging my ear across the carpet because it hurt so bad. He had no understanding for my pain, and of course, was part of the "shake it off, you'll be fine" era of parenting. At some point, he did find me some medicine for swimmer's ear at the local drug store and I remember never being without it as a kid. Eventually, I mastered shaking out my ears so rarely did this ever happen again; that is until I worked in the NICU.


Because vulnerable, little NICU wee ones get their own stethoscope so they aren't being shared from incubator to incubator, this means nurses share and of course, this offered me a new route of exposure. I recognized the pain, tried treating on my own, but ultimately ended up in the emergency room.


This is significant for me, not just because I fully embraced the "shake it off" mindset of my generation, but also because in spite of being a nurse, I also had a lot of personal medical trauma from my childbirth experiences and while I absolutely adored being a nurse, I could not cope as a patient. That imbalance of power shook me to my core, so when I get this call from parents, and they feel bad about "bothering me," but their little ones seems like they in a good deal of pain, I remember well sitting in that emergency room and having to speak up for myself when the medical resident shamed me for coming in for otitis externa and being rough with me in his frustration. Having already had a few children, at home, without a hint of pain medication, I would gladly have done that again to avoid having to present in the emergency room and annoy this young physician. I am glad to be available.



Otitis externa is the medical diagnosis for what ultimately is an inflammation or infection in the ear canal. This is often referred to as "swimmer's ear" because this is often the story clients present with when infection occurs. They had spent the day playing in the water and unbeknownst to them, didn't get all the water shaken out of their ear canal so it created a great breeding environment for bacteria. Sharing any items that enter the ear can also invite this scenario, such as sharing stethoscopes or airpods.


You don't have to take my word for how disabling this can be, and how painful. One study found that it can cause 36 percent of individuals to not be able to complete their typical daily activities for at least four days, and 21 percent require complete bed rest (van Asperen et al., 1995).


Otitis externa is a localized process that is easily controlled with topical agents, so in spite of it feeling really horrible, from my perspective as a clinician, it's pretty easy to treat and really doesn't require follow up. Interestingly, most practitioners will prescribe antibiotics that expose the entire body, most concerning the gut (Halpern et al., 1999), but this isn't necessary or optimal.


Why does this plague some and not others?


The unique structure of the ear canal contributes to the development of otitis externa. Many will share that it impacts one ear more than the other, and this is simply because of the unique structure or the nooks and crannies found in one ear canal but not in the other, or found in one individual and not in another. The insides of our ears are warm, dark and prone to staying moist, especially where there are little nooks and crannies were water can sit and become stagnant. This skin in our ears is thin and it overlies cartilage, while the rest of the ear has a base of bone. When our ear is traumatized or it simply has a funny little curvature within, somewhere along the cartilage or bone, moisture become trapped, especially after a day of swimming or even soaking in the tub, and by night time, bacterial and fungal growth can flourish. The presence of hair, especially the thicker hair common in older men, or even ear wax, can make this even worse.


While ear wax can trap moisture within, it also creates substances that inhibit bacterial and fungal growth. It's also very lipid-rich which prevents water from penetrating the skin and causing maceration. Too little ear wax can predispose the ear canal to infection as well. Use of cotton swabs, hearing aids, ear plus, eczema, psoriasis, or seborrheic dermatitis in the ear makes this all more challenging.


How will I know if my Little One has Otitis Externa?


Your little one will almost always tell you they have pain in their ear and often they will have discharge from their ear, although admittedly the latter hasn't been experience either personally or in clinical practice. It does hurt more when the ear is touched or moved, so tugging on their ear lobe can be exceedingly painful. Chewing can even hurt, so great indicators that there is inflammation or infection in the ear canal. Sometimes, this inflammation can be significant enough to cause swelling in the ear so much that the ear canal is occluded or so that they can't hear from this ear.


If there is discharge from the ear, if it is minimal, white and mucousy, sometimes thick, this is pretty indicative of an acute infection. If it is bloody, then there may be trauma, but this can also occur with chronic bacterial infection. Fungal infections often have a white, flaky or fluffy discharge, but it can also be a black or grey color, even bluish or green. The ear canal in itself is otitis externa (external), but the inflammation can advance to the inner ear or otitis media. Typically this is a deeper pain. There shouldn't be odor either way.


If the ear is full of wax or any other material, this will need to be removed for treatment to be effective. This can be super sensitive, even painful, so a gentle and patient practitioner is important here as well as skilled in technique, because some are more painful, even traumatizing, than others. We would not likely use a cerumen spoon or curette in these circumstances. Suctioning is often preferred, but again, this can be aggressive as can flushing. Direct visualization is important. If these secretions are especially thick or crusted, adding half-strength hydrogen peroxide can soften this material for removal. If it is especially challenge to remove the impaction due to swelling or pain, then the child should be seen more often by the clinician to observe for advancing infection. The tympanic membrane can perforate unknowingly so this should be monitored so they can offer a thorough evaluation of the head and neck.


Typically these infections are the cause of Pseudomonas aeruginosa and Staphylococcus aureus. There are scenarios in which pain medications, including narcotic, may be appropriate, although non-steroidal anti-inflammatory drugs are most often very effective. Fever may be present, but if higher than 101, we need to consider other causes. Swollen lymph nodes can also occur just in front of the ear.


How is Otitis Externa Treated?


Once as much of the ear canal has been cleaned as much as possible, topical antibiotics are typically started. These are dropped directly on the growing bacteria, so generally super effective. Very narrow spectrum medications can be provided so as to disturb as little of the flora as possible, immediately within the ear. Wide spectrum medications may prove necessary, but not typically. Oral antibiotics are only very rarely indicated, but if infection is persistent or the spreading, this may prove necessary. Adding steroids to the ear drops may decrease the inflammation and edema within the canal and resolve symptoms more quickly, but not all studies show this is beneficial. They can also make it a bit more sensitive.


About 10% of the time these cases are fungal, specifically Aspergillus (Sander, 2001). Only about 10% of the time are these fungal cases Candida. Typically this is indicative of having long term inflammation, and more often these are mixed bacteria and fungal growth. These are more often asymptomatic, and will simply be caught on exam. There may be some itching, so if like my mom, if you catch yourself itching your ear with your key, you probably have a fungal infection. Feeling of fullness in the ear is also indicative of fungal infection. Lotrimin may help, although your provider may use other medications in this scenario depending on severity and the health of your tympanic membrane.


How can we prevent otitis externa from happening?


The key here is shaking that water out of the ear. After bathing or swimming, notice that pool of water, that decreased perception in your hearing, and find just the right angle to get that water out. It isn't as noticeable when it is present, but once you clear it, you'll identify it right away. Some do need to use alcohol drops (Swim Ear) to act as an astringent, but this can be a bit irritating. Others may prefer using Burow's solution as an astringent (Star-Otic). I've heard clients utilizing the hair dryer on the warmest setting to dry out their ears as well. You've seen dogs do this and imagine their risk for retained moisture with those big flappy ears. Shake it out.


If you know you are prone to swimmer's ear, try a mixture of one part white vinegar and one part rubbing alcohol prior to and even after swimming, if you have intact tympanic membranes (no active ear infection and no tubes in your ears). Pour in about a teaspoon of the solution and let it drain back out. Avoid anything that would traumatize your ears, such as cotton swabs, paper clips, hairpins, or car keys.


Any time the ear canal is cleaned and the wax removed, the canal is more vulnerable to infection. If there is trauma and the ear becomes wet, a hydrocortisone may help keep infection at bay until the ear heals (Sander, 2001). Barriers can be helpful for those who swim often, but these can also be an irritant so this depends on the person whether this is truly helpful. The swim caps may offer some protection as well.


Offering your little ones probiotics can help prevent the reoccurrence of external ear infections, but is unlikely to treat it once the infection or inflammation is already in full gear. Often my clients prefer botanical therapies to anything more medical, and goop is among the more popular. This is a combination of coconut oil, olive oil, and minced garlic around the ear itself, but not within it. This is likely to be more helpful for guarding or worsening the infection, and increasing lymph drainage, but unlikely to address the infection itself.


Onions as a Treatment for Otitis Externa


Onion juice has long been used to treat ear infections, but again, the risk is doing this with either impaction, so that the juice becomes entrapped, or doing so with an unknown perforation in the tympanic membrane. There is some research that supports the use of quercetin, a flavanoid that's highly concentrated in onions (Brooks, 1986). It's highly anti-inflammatory, but again, the understanding of its effectiveness and overall application is not well understood. Another study supports onions antibacterial properties for killing bacterial growing petri dishes, so again, there is potential here but less understood with regards to application.


Generations before us did often speak of using the onion to treat ear infections though, and even as an early midwife, I remember learning along with way that when anyone is sick in the home, one should cut an onion in half and leave it by the bed or in the home so it can absorb any impurities from the air. This should be discarded the next day and not eaten because it would be full of toxic pathogens. The Potter's New Cyclopaedia of Botanical Drugs and Preparatios, authored by Wren in 1956, it was written, "Who has not heard of roasted onion as a poultice for suppurating turmour or ear ache?"


This was also written in a 1895 text by Fernie, titled Herbal Simples Approved for Modern Uses of Cure, "if employed as a pultice for earache or broken chilblains an onion should be roasted. Where there is a constant and painful discharge of fetid matter from the ear, or where an abscess is threatened with pain, heat and swelling, a hot poultice of roasted onions will be found very useful and will mitigate the pain." This wasn't limited to English literature either, we can see this in Russian folk literature, in the book of Russian Folk Medicine published in 1976.


Certainly worth a try externally. Based on ancient texts, try warming the onion, wrapping it in muslin, and after being cut, put to the onion to the aching ear for relief. Sometimes drops of the onion juice would be dropped into the ear canal, but again, this concerns me simply because of the potential risk of membrane perforation. You might even grate the onion, place it in a fine mesh sieve, and let the juice drip out into a bowl. If the membrane is known to be intact, this juice may benefit the ear canal.


Our Tried and True Antifungal, Antibacterial, & Antiviral Remedy


As mentioned, goop has long been used in my own practice for ailments, such as ear and sinus infections. It's also helpful for athlete's foot. Garlic, part of this potion, can also be used (or mullein oil) around the ear, let it sit overnight, and then wipe away. Some parents have grated garlic into olive oil, which is what I have done with my kids, and again, rubbed this around their ears, under their jaw, and around the front of their neck. We would repeat this twice a day. As the kids got older they would just ask for goop, or steal it from the fridge if they felt poorly. Coconut oil can be part of this combination as well.


Whatever your approach, connect with your trusted provider and work together here because there is risk, there is much to be mindful of, and in collaboration, mom and clinician can work to find the least intrusive, but most supportive approach. Swimmer's ear should start to resolve in the first three days, so if not, another important reason to be connected with your provider.


References

Brooks, D. N. (1986). An onion in your ear. The Journal of Laryngology & Otology, 100, 1043-1046.

Halpern, M. T., Palmer, C. S., & Seidlin, M. (1999). Treatment patterns for otitis externa. Journal of American Board of Family Practice, 12(1), 1-7.

Sander, R. (2001). Otitis externa: a practical guide to treatment and prevention. American Family Physician, 63(5) 927-937.

van Asperen, I A., de Rover, C. M., Schijven, J. F., Oetomo, S. B., Schellekens, J. F., & van Leeuwen, N. J. (1995). Risk of otitis externa after swimming in recreational fresh water lakes containing Pseudomonas aeruginosa. British Medial Journal, 311, 1407-1410.


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