Swimmer's Ear

Summer's here and that means we will soon start seeing a lot of older kids with earaches.

Swimmer's ear differs from a middle ear infection. It is an inflammation of the skin lining the ear canal and is most common in older children and teens. Middle ear infections (otitis media) are caused by pus behind the eardrum and are most common in infants and younger children.

Swimmer's ear (AKA otitis externa) gets its name because it is commonly caused by water in the ear canal making a good environment for bacteria to grow, causing an infection of the skin. Water can come from many sources, including lakes, pools, bath tubs, and even sweat, so not only swimmers get swimmer's ear.

Anything that damages the skin lining the ear canal can predispose to a secondary infection, much like having a scraped knee can lead to an infection of the skin on your knee. Avoid putting anything in your ears, since it can scratch the skin of the ear canal. This includes anything solid to clean wax out of the ear. Excess earwax can trap water, so cleaning with a safe method can help prevent infection. A little wax is good though -- it actually helps prevent bacterial growth. For more on earwax, please see Ear Wax: Both Good and Bad.

Swimmer's ear can cause intense pain. Sometimes it starts as a mild irritation or itch, but pain worsens if untreated. It typically hurts more if the ear is pulled back or if the little bump at the front of the ear canal is pushed down toward the canal. Ear buds (for a music player) or hearing aides can be very uncomfortable (and increase the risk of getting swimmer's ear due to canal irritation). Sometimes there is drainage of clear fluid or pus from the canal. If the canal swells significantly or if pus fills the canal, hearing will be affected. More severe cases can cause redness extending to the outer ear, fever, and swollen lymph nodes (glands) in the neck. Swimmer's ear can lead to dizziness or ringing in the ear.

Prevention of swimmer's ear is possible for most people.

• If your child has excessive wax buildup, talk with his doctor about how often to clean the wax. (Wax does help keep your ears clean, so you don't want to clear it too much!)
• Never put anything solid into the ear canal.
• Dry the ear canals when water gets in. 

• Tilt the head so the ear is down and hold a towel at the edge of the canal. 
• Use a hair dryer on a cool setting several inches away from the ear to dry it. 

• If kids get frequent ear infections or are in untreated water (such as a lake), use over the counter ear drops made to help clean the canal. You can buy them at a pharmacy or make them yourself with white vinegar and rubbing alcohol in a 1 to 1 ratio. Put 3-4 drops in each ear after swimming. The acid of the vinegar and the antibacterial properties of the alcohol help to clear bacteria, and the alcohol evaporates to help dry the canal. DO NOT use these drops if there are tubes or a hole in the eardrum, if pus is draining, or if the ear itches or hurts.

• If your child has a scratch in the ear or a current swimmer's ear infection, avoid swimming for 3-5 days to allow the skin to heal. 
• Avoid bubble baths and other irritating liquids that might get into ear canals.
• If your child has tubes placed for recurrent middle ear infections, talk with your ENT about ear protection during swimming. 

Treating swimmer's ear:

• If you think your child has swimmer's ear, start with pain control at home with acetaminophen or ibuprofen per package directions. Heating pads to the outer ear often help, but do not put any heated liquids into the ear. 
• Most often swimmer's ear is not an emergency, but symptoms can worsen if not treated with prescription ear drops within a few days. Bring your child to the office for an exam, diagnosis, and treatment as indicated. 
• If the pain is severe, redness extends onto the face or behind the ear, the ear protrudes from the head, or there are other concerning symptoms, your child should be seen immediately at our office or another urgent/emergent care setting. 
• Occasionally we will remove debris from the canal or insert a wick to help the drops get past the inflamed/swollen canal. Never attempt this at home!
• The prescription ear drops may include an antibiotic (to kill the bacteria), a steroid (to decrease inflammation and pain), an acid (to kill bacteria), an antiseptic (to kill the bacteria), or a combination of these.  They are generally used 2-3 times/day. Have the patient lie on their side, put the drops in the ear and remain on that side for several minutes before getting up or changing sides to allow the medicine to stay in the ear. Symptoms generally improve after 24 hours and the infection clears within a week.
• Oral antibiotics are usually not required unless the infection extends beyond the ear canal.
• If pain is very severe, ask about prescription pain relievers when your child is being seen and evaluated. Most often they are not needed, but if they are it is best to get them at the time of your visit so risks of these medications and how and when to use them can be discussed.
• If an infection causes more itch than pain or does not clear with initial treatment, we might consider a fungal infection, which requires an anti-fungal medication. 
• No swimming until the infection clears. 
• Kids (and adults) with diabetes or other immune deficiencies are more likely to get severely sick with any infection. Visit your doctor early if you suspect a problem.

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Ear Wax: Both Good and Bad

Ear Wax Removal NOT Recommended

We make ear wax, also known as cerumen. Many people are annoyed by wax buildup, but it has a purpose! Wax grabs all the dust, dirt, and other debris that gets into our ears. It also moisturizes the ear canal ~ without it our ears become itchy. It even has special properties that prevent infection. That's all good stuff, so don't be too frustrated with a little wax!

Most often the wax moves from the inner part of the ear canal to the outer edge of the canal on its own.  It is amazing to me how our bodies are put together so perfectly: it is designed so the wax is made deep in the canal, then skin cells and wax migrate to the outer edge of the canal, taking with them debris! Some people naturally make dry wax, others make wet wax. This can be due to genetics and other factors. The important thing to remember with this is how your wax tends to build up and how to best keep it from building up.

If wax builds up it can cause pain, itching, ringing in the ear, dizziness, decreased hearing, and infection.  Inappropriate cleaning with hard and/or sharp objects (such as an cotton swabs or paperclips) can increase the risk of infection or even perforation of the ear drum.  Even special cotton swabs made "safe for ears" can push wax deeper and cause a solid collection of wax plugging up the canal.

How can parents help babies and kids keep their ears clean?

Routine bathing with clean warm water allowed to run into the ear followed by a gentle wiping with a cloth is all that is needed most of the time. 

Ear drops made for wax removal with carbamide peroxide can be put in the ear as long as there is no hole in the ear drum or tubes.  The oily peroxide acts to grab the wax and bubble it up. Then rinse with clean warm water and a soft cloth (see syringe tips below). If there is excessive buildup, daily use of drops for 3-5 days followed by weekly use of the drops to prevent more buildup is recommended. (For particularly stubborn wax, using drops 2-3 times/day for 3-5 days initially can help.)

Make your own solution of 1:1 warm water:vinegar and gently irrigate the ear with a bulb syringe.  

Mineral oil or glycerin drops can be put in the ear. Let a few drops soak for a few minutes and then rinse with warm water and a soft cloth. 

Occasional use of a syringe to gently irrigate the ear can help. Using the bulb syringe:

• First, be sure it is clean! Fungi and bacteria can grow within the bulb ~ you don't want to irrigate the ear with those!  While they can be boiled, they are also relatively inexpensive and easily available, so frequent replacement is not a bad idea.
• Use only warm water /fluids in the ear (about body temperature or just above body temperature is good). Cold fluids will make the person dizzy and possibly nauseous! If using drops first, put the bottle in warm water or rub it between your hands a few minutes (as if rubbing hands together to warm them, but with the bottle between the hands). Don't overheat the fluid and risk burning the canal!
• Have the child stand in the tub or shower.
• Pull up and back gently on the outer ear to straighten out the canal.
• Aim the tip slightly up and back so the water will run along the roof of the canal and back along the floor. Do NOT aim straight back or the water will hit the eardrum directly and can impact hearing. 
• Don't push the water too fast ~ a slow gentle irrigation will be better tolerated. If they complain, recheck the angle and push slower. If complaining continues, bring them to the office to let us do it to be sure there isn't more to the story.
• Refill the syringe and repeat as needed until the wax is removed. 
• Use a soft cloth to grab any wax you can see and dry the ear when done. Some people like to use a hair dryer set on low to dry the canal. Just be sure to not burn the skin! 

If wax continues to be a problem, we can remove it in the office with one of two methods:

After inspecting the ear canal carefully with an otoscope (or as I call it with the kids: my magic flashlight), we can use a curette (looks like a spoon or a loop depending on provider's preference and wax type) to go behind the wax and pull it out.  This is often the fastest method in the office, but is not always possible if the wax is too flaky or impacted into the canal leaving no room for the curette to pass behind the wax.  It should only be done by trained professionals... don't attempt this at home!

If the wax is plugging up too much of the canal, the canal is very tender, or if the wax is particularly flaky and breaks on contact with the loop, we will let the ear soak in a peroxide solution then irrigate with warm water. This process takes longer but is better tolerated by many kids and they think it is fun to "shower their ear".  We often must follow this with the curette to get the softened wax completely out. 

My biggest tips:

Not Safe!

• Never use cotton tipped swabs, pipe cleaners, pencils, fingernails, or anything else that is solid to clean the ear! (Note: I still don't recommend them if the package says "safe" ~ they aren't!)
• Don't put liquid in the ear canal if there is a hole in the ear drum (tubes are included in this). Pus draining from the ear is a sign that there might be a hole.
• Ear candles are not a safe solution. Burns are too big of a risk!
• The ear canal is very sensitive, especially if wax buildup has been there a while and has caused an infection of the skin in the canal.  Anything put into the ear can increase any pre-existing pain. 
• If the skin is friable from prolonged wax and/or infection there is often bleeding with cleaning. If you notice this at home, your child should have the ears evaluated in our office. We will look for holes in the ear drum, scratches on the skin in the canal, and signs of infection needing antibiotic.
• Some people who suffer from itchy ears can help themselves by NOT cleaning their ears so much!
• Earwax usually can be left alone. Only try to clean it out if there are signs of problems with it (ear pain, ringing in the ears, decreased hearing, etc). If kids don't tolerate removal with the methods above, bring them in for us to take a good look. There might be more to the story that needs to be addressed. 
• If there is significant ear pain, pus or bleeding from the ear, or an object in the ear, bring your child in to the office to have us assess and treat.

UPDATE:

In January of 2017, the American Academy of Otolaryngology-Head and Neck Surgery Foundation issued updated AAP-endorsed guidelines regarding wax buildup. Check out this list of Do's and Don'ts from the guidelines.