Swimmer’s Ear: Be on the Alert For Complications

As spring spreads across the country, the change in temperature and slanting of the sun promises that summer is soon on its heels. For many primary care physicians and otolaryngologists, particularly those living in northern climes, that means an upsurge in people presenting with acute otitis externa, a condition that is estimated to afflict from 1 in 100 to 1 in 250 persons in the general population.

For most patients, standard treatment with topical antibiotics or antiseptics is sufficient and safe. For some patients, particularly those with diabetes or conditions that compromise their immune system, treatment can be more complex, as these patients are at higher risk of complications.

For most otolaryngologists, diagnosis and treatment of this condition is fairly straightforward, according to Peter S. Roland, MD, Professor and Chairman of Otolaryngology-Head and Neck Surgery at UT Southwestern Medical Center in Dallas, who coauthored the clinical practice guidelines on acute otitis externa endorsed by the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS; www.entnet.org/Practice/upload/AOE-cpg.pdf ).

Dr. Roland emphasized, however, that otolaryngologists need to pay special attention to particular populations of patients in whom this condition may wreak more havoc and be more difficult to treat. And perhaps the most important message to otolaryngologists is the need to recognize the potential toxicity of one of the most widely used topical antibiotic agents used as first-line therapy.

The guidelines recommend that ototoxic topical antibiotics be avoided unless people are reasonably confident that the eardrum is intact, he said.

Along with these special treatment considerations, otolaryngologists need to pay attention to pain as a diagnostic indicator of potential risk of complicated swimmer’s ear and as an important factor to treat for optimal management.

Importance of an Intact Eardrum to Avoid Ototoxicity

Standard treatment for uncomplicated, straightforward cases of acute otitis externa is the use of either an antiseptic or an antibiotic topical agent. All the currently used agents in both categories are largely safe for most patients. However, ototoxicity has been reported in patients treated with aminoglycosides (neomycin, gentamicin, tobramycin) if the drops get into the middle ear space through a puncture in the eardrum and are absorbed into the inner ear.

The determining factor for the risk these agents pose is whether the eardrum is intact or not. If the eardrum is intact, these agents are not toxic, said John A. Rutka, MD, Professor of Otolaryngology-Head and Neck Surgery at the University of Toronto, who has been on the forefront of writing on the potential ototoxicity of these agents.