How Should Swimmer's Ear (Acute Otitis Externa) Be Managed?

Judith S. Lynch, MS, MA, APRN-BC


July 01, 2011

In This Article


Why is swimmer's ear so common in the summer months, and how should it be managed in primary care?

Response from Judith S. Lynch, MS, MA, APRN-BC
Assistant Clinical Professor, Yale School of Nursing, Milford, Connecticut; Advanced Practice Nurse Practitioner, Naugatuck Valley ENT Associates, Waterbury, Connecticut

Swimmer's Ear -- Acute Otitis Externa

Swimmer's ear, or acute otitis externa (AOE), is an inflammation or infection of the external auditory canal that may or may not include the auricle.[1]It is a common health problem that is seen more frequently in hot weather, particularly in emergency departments during summer vacations.

AOE affects swimmers (hence the name) because their ears are frequently exposed to water. This creates a warm and moist environment, allowing microorganisms to thrive. Individuals with allergic conditions (eczema, allergic rhinitis, asthma) also have a significantly higher risk for this condition developing.[1]

Other risk factors include:

  • Absence of cerumen with development of dry skin in the ear canal;

  • High humidity and increased temperature;

  • Local trauma, especially from the use of cotton-tipped swabs;

  • Wearing hearing aids and headphones;

  • Presence of exostosis (bony prominences in the canal from exposure to cold water -- often found in surfers);

  • Narrow, curved, or tortuous auditory canals, allowing retained moisture; and

  • Ear piercings.

Incidence and Prevalence of AOE

A study published in the May 20, 2011, Morbidity and Mortality Weekly Report[2] stated that AOE adds substantially to healthcare costs and to the number of annual provider visits. Findings included:

  • One in 123 Americans consulted a provider for swimmer's ear in 2007;

  • From 2003-2007, children ages 5-14 years had the highest annual visits for swimmer's ear;

  • More than 50% of these visits were by adults 20 years and older;

  • Cases peak during summer months;

  • 2.4 million heathcare visits for swimmer's ear per year cost half a billion dollars, not including time lost from work and school activities; and

  • AOE has no gender or racial predilection.[3]

Classification of AOE

  • Acute diffuse OE: the most common form, often seen in swimmers;

  • Acute localized OE (furunculosis): associated with an infected hair follicle;

  • Chronic OE: an acute infection lasting longer than 6 weeks;

  • Eczematous OE: arises from atopic dermatitis, psoriasis, and other dermatologic conditions; and

  • Necrotizing "malignant" OE: extends into deeper tissue adjacent to the auditory canal; occurs in immunocompromised adult patients (those with diabetes, AIDS); may result in cellulitis or osteomyelitis.

Pathophysiology of AOE

The presence of cerumen is a healthy defense for the external auditory canal. It is generally acidic (pH 4-5). Cerumen inhibits bacterial or fungal growth and its waxy nature also protects the underlying epithelium from maceration or skin breakdown.

Many individuals have a preoccupation with cerumen, often using various instruments to remove it (flushing syringes, pencils, paper clips, cotton-tipped swabs, etc). This leads to irritation and drying of the canal and skin breakdown and allows an entry point for bacteria or fungi.

AOE develops in swimmers because of excessive water exposure. This reduces cerumen, leading to canal dryness and pruritis. If individuals then insert objects as described above, it results in inflammation and infection.

The most common organisms involved in AOE are:

  • Pseudomonas aeruginosa (50%)

  • Staphylococcus aureus (23%)

  • Anaerobes and gram-negative organisms (12.5%)

  • Fungi: Otomycosis is an infection caused by Aspergillus species (80%-90% of the time). Otomycosis is easily identified by long white filaments of hyphae growing from the canal surface. These filaments are often surrounded by black strands.[3]


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