What is swimmer's ear?

(otitis externa)is an inflammation or infection of the outer ear canal, and is distinguished both in location and cause from the inner (middle) ear infections (otitis media) common in infants and toddlers.

What causes it?

It is often caused by a variety of common organisms, including some types of bacteria and fungi. However, it can also have purely physical causes. When it occurs among swimmers, three elements are usually present:

• the ear canal is alkaline, rather than acid,
• the ear canal is damp or wet, &
• an infectious agent is present.
  
  

Explanations

Swimming in pools almost always provides the first two conditions, since pools are wet (!) and usually slightly alkaline. The ear itself provides the third condition, since many of the organisms often involved in ear infections are already normally present in the ear canal, at least in small quantities. Voila': your swimmer has met all the minimum requirements for an infection

But, since some of the causative organisms (esp., some varieties of Psuedomonas) are quite resistant to most pool sanitizers, swimmers often get an extra helping from some pools, including some that are otherwise well sanitized. And in many natural waters some of these organisms are almost always present.

How can you avoid swimmer's ear?

While the obvious -- if unhelpful -- answer, "don't get your ears wet", is often provided in literature from medical sources, most swimmers find less drastic measures are sufficient.

• Dry your ears after swimming;
• Remove excess water from your ear canal with a 'head-shake'
  
• Use ear drops after swimming; &
• If you are particularly susceptible, use ear drops before swimming, as well.
  
  

Many regular swimmers become adept at shaking their head at the right angle and in the right rhythm to remove excess water. But children and occasional swimmers may not be able to do this "head-shake" maneuver effectively. Many drops contain fluids (like various alcohols) that not only get into the ear easily, but then mix with the trapped water, and help it get OUT. So drops are a good idea for those not adept at removing trapped water.

Also, some pool users seem to be MUCH more susceptible swimmer's ear or otitis externa, for whatever reasons, than others. For them, regular use of ear drops can prevent a lot of misery.

While ear infections often occur after swimming even in well sanitized pools, if 20% or more of a swim team gets infections simultaneously, there is a good chance that one of the pools they have recently swum in is badly sanitized.

And, keep in mind that if you've (or your child) has had multiple cases of otitis externa, REGULAR preventative use of non-irritating ear drops can work wonders, and should be a part of your swimming routine. Drops and swimsuits should go together!

What kind of drops should you use?

Rubbing alcohol is often recommended for use as ear drops. However, rubbing alcohol burns or stings at best, especially on young swimmer's skin, and may hurt like the devil if the ear canal is already slightly inflamed or irritated. (Some other, less common, types of alcohol are NOT irritating, and are used in commercial ear drops.)

Keep in mind that if your swimmer ALREADY has an ear that is hurting and infected, you may have to peel them off the ceiling after putting alcohol in their ears. And once you do get them down you may find yourself the recipient of a (deserved!) verbal tirade.

Less drastic -- and probably more effective -- is a mixture of 1/2 vinegar and 1/2 hydrogen peroxide. Once the peroxide is added, the mixture is perishable, so don't mix more than you'll use in a week or so. The peroxide can lose its strength rather quickly once mixed. Vinegar alone is a good preventative since it restores the ear canals acidity.

A laboratory wash bottle, filled with this mixture, and used routinely on swim team members (line 'em up, squirt it in!) is cheap and seems to eliminate problems almost completely. But check with parents: there are some bizarre sensitivities out there -- and some bizarre parents!

But, please be careful. Don't jab the bottle nozzle in some wiggly kid's ear! You may want to trim and round the nozzle so it's less 'pointy'. And, though this mix doesn't irritate most peoples ears, it feels pretty AWFUL in EYES! Having the kids hold a towel over their eyes, as you squirt, is a good idea.

Much better, in my family's personal experience, are WERE the commercially available Star-otic drops. Unfortunately, although "StarOtic" brand drops are still available, the new "StarOtic" drops are not the same as the old "StarOtic" drops, and do not work nearly so well. The only thing close to the old drops is a generic version of Bayer's Dromboro, made by Bausch & Lomb and retailed for $70.00 + a prescription.

You can thank the FDA's ponderous bureaucracy. Their involvement in this is the precisely same sort of massively expensive government oversight which has resulted in no new pool algaecides in 30 years! Although, Star-Otic (Burrough's Solution) worked well for years, they  did not have the expensive testing the FDA wanted. And, since it was a low volume niche product, there was no way to pay for those tests. So, the company dropped the product, but kept the brand and filled the bottle with a fairly useless blend of alcohol and what not.

The next best thing -- if you don't want to spend $100 for a tiny bottle of drops -- is to make your own from vinegar and peroxide. It's not, in my non-medical, swim-father's opinion, as good as good as the old StarOtic. But, it's better than the new StarOtic, and it does work. And that's more than I can say for the new StarOtic. We used up our last saved bottle of old StarOtic this summer (2010), and had to finally make the switch ourselves. (At least till I buy some glycerol, aluminum acetate, & boric acid and make my own!) [UPDATE: see links below for a recipe from the "Scuba-Doc" that's close to the original Star-Otic.]

When should I go to the doctor?

The obvious and legally acceptable answer is: ask your doctor.

However, my non-medical opinion is: if your ear really hurts a lot, has a discharge or pus, or if you have a fever, you should go. Also, if you have had problems in the past with serious ear infections, you should probably hustle down to his office, sooner rather than later. A bad infection can be a real mess.

Our family's experience with preventing and treating swimmer's ear infections fortunately never included those advanced infections, but we saw plenty of kids who had them.

My ear (or my child's ear) isn't oozing or anything like that. It hurts, but that's all. Do I need to go to the doctor?

The legally acceptable answer is: ask your doctor.

I can tell you our family's experience, however.

Currently, I have a 23 year old son, who's been swimming since he was 4 years old, and a 15 year old who's been swimming competitively since he was 5. Both still swim 1,000's of yards each week. Over the years, they've probably averaged 1 case of otitis externa per year, usually after swimming in a badly sanitized pool. They use (or ask for) drops at the first sign of ear pain. Their ear pain has always disappeared within 3 days of starting drops, and they've never had to go to the doctor OR stop swimming.

But, their ears have never gotten to the nasty oozy REALLY painful stage we've seen on other swimmers.

Are there any medical references -- I'd like to check what you say?

Yep, we had several with the original version of this article. But the links don't work anymore.

So, we've got new links. But I'm gonna be smart this time, so I've saved and attached copies of those articles.

When you read them, keep in mind that doctors tend to see cases of otitis externa only after they get to the "I can't stand it any more" stage. So they describe really painful and really disgusting cases. My boys have never had one of those, and neither have their friends, once we explained what we did to avoid! But, if your child gets to the "really hurting" and/or "oozing disgustingly" or "is running a fever" state . . . you're way past the 'drops will help' state: GO TO THE DOCTOR!

My purely personal, non-medical, swim-father's opinion is that the "how to avoid" advice found in these articles is pretty poor; I'm guessing none of the doctors who penned these things had children who swim. But, they're doctors, so read and make up your own mind.

---

AAFP "Otitis Externa: A Practical Guide to Treatment and Prevention"
Link to AAFP page -- local copy (downloaded & zipped 17Aug2010)

AAFP "Information from Your Family Doctor - Otitis Externa" (non-medical version of above)
Link to AAFP page -- local copy (downloaded & zipped 17Aug2010)

Emedicine "Otitis Externa: Treatment & Medication"
Link to Emedicine page -- local copy (downloaded & zipped 17Aug2010)

Drugs.com "DomeBoro Otic"
Link to Drugs.com page -- local copy (downloaded & zipped 17Aug2010)
[ Article incorrectly states that StarOtic is generic for DomeBoro. This has not been true for years! ]

Scuba-Doc.com "Otitis Externa"
Link to ScubaDoc.com page -- local copy (downloaded & zipped 17Aug2010)
[ found this one Aug 2010. It's the first really practical page, other than my own, I've seen on the web. He's a retired doctor, a former swimmer, and a diver . . . AND, he includes a recipe (2nd one) for StarOtic!  Excellent page. ]

Revision 1.3 Copyright Ben Powell 2011 - All rights reserved
Revision 1.1 4/8/99 - BMP;  Revision 1.0 1997 - BMP Revisions 1.0 & 1.1 Copyright PMBWebpages & Ben Powell 1997 - 1999

Other articles about Otitis Externa?

InteliHealth Otitis Externa Article

National Institutes of Health Otitis Externa Article

These articles are superior to the CDC article found here which focuses exclusively on psuedomonas aeruginosa as the cause of O.E.. This is unhelpful, since it will lead to pool operators trying to 'fix' O.E. by raising sanitizer levels. While anyone one who knows me, knows I prefer my chlorine levels high, such an approach is not helpful to parents of those kids who tend to acquire O.E. simply from wet ears.

Revised 3/18/2011 - BMP

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