Otitis externa (or swimmer's ear)

What is otitis externa?

Otitis externa is inflammation and often infection of the skin lining your ear canal, the tube between your outer ear and your eardrum. It is often called "swimmer’s ear" because regularly getting water in your ear makes this inflammation more likely.

What are the symptoms of otitis externa?

Usually, only one ear is affected. Symptoms can include:

• itching, pain or discomfort in the ear canal, often worse when you touch or tug your outer ear
• a feeling of fullness in the ear
• discharge from the ear, which may be watery, or thicker and smelly if the infection is worsening
• dry, flaky skin around the outside of the ear
• temporary dulled or muffled hearing, if swelling narrows the ear canal
• discomfort moving your jaw when chewing or speaking
• in more severe cases, fever and swollen lymph nodes around the ear or neck

With treatment, symptoms usually clear up within about a week, though some cases take several months or longer.

What causes otitis externa, and who is at risk?

Most cases are caused by a bacterial infection, most often with the bacteria Staphylococcus aureus or Pseudomonas aeruginosa. Less commonly, otitis externa is caused by a fungal infection, such as Candida or Aspergillus, or rarely a virus.

Getting water, shampoo or soap into your ear canal can irritate the skin and make it itch. Scratching or poking the ear canal, including with cotton buds, can then damage the skin and lead to inflammation and infection.

You may be more likely to develop otitis externa if you:

• regularly get water in your ears, for example from swimming, frequent baths or showers
• have a skin condition such as eczema or psoriasis affecting your ear canal
• use hearing aids, earplugs or earbuds, which can trap moisture or introduce dirt
• have lost some of your earwax, which normally helps protect the ear canal
• live in, or are visiting, a hot, humid climate
• have a weakened immune system

Otitis externa is quite common. It is estimated that around 1 in 10 people will be affected at some point in their lives, and it happens most often in older children, young teens, and adults aged 45 to 75.

Are there different types of otitis externa?

Otitis externa is generally described in a few ways:

• acute otitis externa, lasting less than six weeks, most often caused by a bacterial infection
• chronic otitis externa, lasting more than three months, often linked to an allergy or an underlying skin condition
• localised otitis externa, a small, boil-like infection in one spot in the ear canal
• diffuse otitis externa, which affects the skin of the whole ear canal, and is the more common pattern.

Rarely, the infection spreads into the surrounding cartilage or bone, which is a more serious complication that needs specialist treatment.

How is otitis externa diagnosed?

A pharmacist, GP or nurse will usually ask about your symptoms and whether you regularly put anything into your ears, such as hearing aids or earplugs. They will often examine inside your ear using an instrument called an otoscope, checking for redness, swelling and discharge.

If you have otitis externa often, or treatment has not helped, your doctor may take a swab of the inside of your ear. This is tested to check what type of infection you have, if any, so that the right medication can be prescribed.

Otitis externa can sometimes be confused with a middle ear infection, especially in children. A middle ear infection more often causes pain that is worse when lying down, along with vomiting, diarrhoea or a reduced appetite, and needs different treatment.

How is otitis externa treated?

Ear drops or a spray usually clear otitis externa within about a week. These typically combine an antibiotic, to clear the infection, with a steroid, to reduce inflammation and itching, and are normally used several times a day for about a week to 10 days.

Other treatments your doctor or nurse might use include:

• cleaning your ear canal, using gentle suction or mopping to remove discharge and debris
• a small dressing (sometimes called a wick), soaked in ear drops and placed in the ear canal if it is very swollen, to help the medication reach all the way in
• antibiotic tablets, in addition to drops, if the infection is severe
• painkillers such as paracetamol or ibuprofen to ease discomfort

Surgery is not usually needed for otitis externa. If your symptoms are severe, keep coming back, or do not improve with the treatments above, your GP may refer you to an ear, nose and throat (ENT) specialist for further assessment.

While you are being treated, it helps to:

• avoid swimming until the condition has fully cleared
• keep the affected ear dry, for example by wearing a shower cap or using a cotton wool ball coated in Vaseline when showering or bathing
• remove anything that could be causing an allergic reaction, such as hearing aids, earplugs or earrings
• gently wipe away any discharge from the outside of your ear with cotton wool, without putting cotton wool or a cotton bud inside the ear canal.

When should I see a doctor?

A pharmacist can often give advice and treatment for otitis externa, and may suggest you see your GP if needed.

Contact your GP or nurse if:

• your discharge increases or becomes smelly
• your outer ear becomes very red, swollen, tender or painful
• you develop a temperature and feel unwell or feverish
• redness starts spreading from your ear towards your face or neck
• your symptoms have not improved after about a week to 10 days of using ear drops