Paediatric Hearing - Otitis Externa (Swimmers Ear)

What is Otitis Externa (Swimmer's Ear)?

Otitis Externa, also known as swimmers ear (, is a common condition characterised by inflammation, infection, or irritation of the outer ear canal. It often occurs when water remains trapped in the ear after swimming or bathing, providing a moist environment conducive to bacterial or fungal growth.

Acute otitis externa

inflammation of <6 weeks
rapid onset within 48 hours
causes: bacterial infection with Pseudomonas aeruginosa or Staphylococcus aureus.
associated with underlying skin conditions including contact dermatitis; acute otitis media; trauma to the ear canal; foreign body or obstruction in the ear canal; and water exposure.

Chronic otitis externa

inflammation >3 months
causes: fungal infection with Aspergillus species or Candida albicans
associated with diabetes mellitus or other causes of immunocompromise; or fungal infection due to prolonged topical antibiotic or corticosteroid use.

Signs and symptoms of acute and chronic otitis externa:

Signs	Typical signs of Acute Otitis Externa	Typical signs of Chronic Otitis Externa
Tenderness of tragus/pinna	Present	N/A
Ear canal appearance	Red, oedamatous	Lack of ear wax, dry scaly skin
Tympanic membrane appearance	Erythema	N/A
Other signs	N/A	Conductive hearing loss, fluffy cotton-life black debris may be seen in the ear canal if fungal infection

Symptoms	Typical symptoms of Acute Otitis Externa	Typical symptoms of Chronic Otitis Externa
Ear itch	Present	Constant itch in the ear
Ear discharge	Present	N/A
Ear pain	Present	Mild discomfort or pain
Tenderness of tragus/pinna	Present	Present
Jaw pain	Possible	N/A

Diagnosis

Diagnosis of otitis externa is primarily clinical and based on patient history and physical examination (otoscopy and check lymph nodes).

Ask about any possible causes or risk factors, including recent ear trauma, use of hearing aids or ear plugs, history of head or neck radiotherapy.

Additional tests such as ear swabs for culture and sensitivity may be conducted to identify the causative organism and guide treatment if the condition is severe or recurrent.

Management of Acute Otitis Externa

Keep the ear dry and clean (eg. avoid swimming for 7-10 days)
Consider use of over-the-counter acetic acid 2% ear drops or spray (for people aged 12 years and older) morning, evening, and after swimming, showering, or bathing, for a maximum of 7 days.
OTC analgesia – paracetamol/ibuprofen
Consider prescribing a topical antibiotic preparation with or without a topical corticosteroid for 7–14 days (please refer to your local guidelines).
Arrange follow-up if no improvement within 48-72 hours of starting initial treatment, symptoms not resolved after 2 weeks, cellulitis present beyond ear canal

Management of Chronic Otitis Externa

Keep the ear dry and clean (eg. avoid swimming for 7-10 days)
Consider use of over the counter (OTC) acetic acid 2% ear drops or spray (for people aged 12 years and older) morning, evening, and after swimming, showering or bathing for a maximum of 7 days
OTC analgesia – paracetamol/ibuprofen
Consider prescribing a topical ear preparation, depending on clinical judgement.
If there are signs of fungal infection in the ear canal, options include:
A topical antifungal preparation, such as clotrimazole 1% solution applied 2–3 times a day, to be continued for at least 14 days after infection has resolved.
Clioquinol and a corticosteroid 2–3 drops twice daily for 7–10 days.
Over-the-counter acetic acid 2% ear drops or spray (off label-indication, for people aged 12 years and older) morning, evening, and after swimming, showering, or bathing, for a maximum of 7 days.
If there is suspected bacterial infection, manage as for acute otitis externa.
If there is no obvious fungal or bacterial infection:
Consider prescribing a topical corticosteroid preparation such as prednisolone ear drops 2–3 drops every 2–3 hours until symptoms improve, or betamethasone ear drops 2–3 drops 3–4 times a day. If symptoms improve, continue treatment using the lowest potency and/or frequency of application needed to control symptoms.
If symptoms persist despite topical corticosteroid treatment, consider a trial of a topical antifungal preparation instead.

When to Refer for Acute Otitis Externa	When to Refer for Chronic Otitis Externa
Emergency Hospital Admission or Urgent Referral:	Emergency Hospital Admission or Urgent Referral:
Suspected malignant otitis externa or serious complications based on clinical judgement.	Suspected malignant otitis externa or serious complications based on clinical judgement.
Seek Specialist Advice or Referral to ENT Specialist (Urgency Depending on Clinical Judgement):	Seek Specialist Advice or Referral to ENT Specialist (Urgency Depending on Clinical Judgement):
Symptoms persist despite optimal management in primary care.	Symptoms persist despite optimal management in primary care.
Severe infection not responding to primary care management.	Ongoing need for topical treatment beyond 2–3 months for symptom control.
Elderly patients or those with poorly controlled diabetes mellitus or other immunocompromising conditions.	Elderly patients or those with poorly controlled diabetes mellitus or other immunocompromising conditions.
External ear canal occlusion obstructing topical treatment effectiveness.	Ear canal occlusion hindering effective use of topical treatment.
Need for specialist 'aural toilet' procedures like microsuction, ear wick insertion, or systemic antibiotics.	Need for specialist procedures like microsuction or ear wick insertion.
Cellulitis extending beyond the external ear canal that cannot be managed in primary care.	Cellulitis extending beyond the external ear canal that cannot be managed in primary care.
Consider Dermatology Referral:	Consider Dermatology Referral:
Suspected contact sensitivity to neomycin or another aminoglycoside ear preparation, ear plugs, hearing aids, or earrings.	Suspected contact sensitivity to neomycin or another aminoglycoside ear preparation, ear plugs, hearing aids, or earrings.
Patch testing may be necessary to confirm contact sensitivities.	Patch testing may be necessary to confirm contact sensitivities.