Swimmer’s ear — ear pain after swimming, trapped water and discharge

After swimming, water may remain trapped in the external ear canal, soften the protective layer of earwax, and cause maceration of the skin. Bacteria can penetrate through microcracks, most commonly Pseudomonas aeruginosa and Staphylococcus aureus; fungal inflammation develops less often. A feeling of blockage, itching, increasing pain, tenderness when touching the tragus or pulling the auricle, swelling of the ear canal, reduced hearing, and discharge may occur. The fluid draining from the ear is no longer simply water left behind after swimming, but inflammatory exudate. The condition is more common in children because their ear canals are narrower, while older adults, people with diabetes mellitus, and patients with immunodeficiency have a higher risk of the infection spreading. With appropriate treatment, noticeable improvement usually begins within 48–72 hours, and recovery generally occurs in about 7–10 days.

How to tell whether you have otitis externa

Symptoms characteristically appear after swimming, showering, spending time in a hot and humid climate, or using cotton swabs, earphones, or earplugs. The most characteristic sign is increased pain when pressing on the tragus or moving the auricle. The sensation of “water in the ear” is caused not only by moisture but also by swelling, exudate, and narrowing of the ear canal. The diagnosis is confirmed by an otorhinolaryngologist during otoscopy, with assessment of the skin of the ear canal, the nature of the discharge, and the condition of the eardrum. If inflammation is severe or recurrent, examination of the discharge may be required. If the pain feels deep inside the ear, does not worsen when the auricle is moved, and is accompanied by a runny nose, fever, or a bulging eardrum, otitis media must be ruled out. White, gray, or black material and pronounced itching may indicate otomycosis, while bloody discharge, dizziness, or sudden hearing loss may indicate trauma or damage to the eardrum.

Red flags

Immediate examination by an ENT specialist is required for severe, especially nighttime pain that is markedly greater than the visible changes would suggest; spread of redness and swelling to the auricle, face, or neck; high fever and rapidly worsening condition; marked hearing loss; dizziness, vomiting, tinnitus, or impaired balance; bloody discharge; swelling behind the ear or displacement of the auricle; or weakness of the facial muscles. Particular caution is required in patients with diabetes mellitus, immunodeficiency, those undergoing cancer treatment, older adults, and people who have undergone ear surgery, because an external ear infection may spread to cartilage, soft tissues, and the bone at the base of the skull. A child should be examined by a doctor on the same day that discharge, severe pain, or noticeable hearing loss appears.

First-aid measures for otitis externa

Until the ear has been examined, it should be kept dry: stop swimming, do not submerge the head in water, and do not direct the shower stream into the ear canal. After washing, gently blot only the auricle with a clean tissue. Careful drying with cool or barely warm air from a hair dryer is acceptable from a distance of at least 30 centimeters for 30–60 seconds. During a shower, the entrance to the ear may be covered with a cotton ball lightly coated with petroleum jelly, without pushing it inside; remove it immediately after showering.

To reduce pain, a dry warm cloth at a comfortable temperature may be applied externally for 10–15 minutes. A pain reliever may be used only if there are no individual contraindications. No special diet is required: normal eating and drinking may be continued, guided by thirst and by any restrictions related to heart or kidney disease or disorders of carbohydrate metabolism.

Once discharge has appeared, alcohol, vinegar, hydrogen peroxide, boric acid, chlorhexidine, vegetable oils, or arbitrary ear drops should not be instilled into the ear without medical guidance, because perforation cannot be ruled out until the eardrum has been examined. Do not irrigate the ear with a syringe or attempt to remove the “water” using a cotton swab, twisted tissue, hairpin, or any other object. This traumatizes the skin, pushes discharge deeper, and may damage the eardrum. If pain or discharge persists, examination is required within the next 24 hours; if the condition worsens, it should be performed sooner.

Stages and possible progression of otitis externa

Initially, there is a sensation of moisture, blockage, and itching. Redness, swelling, and tenderness then increase; the ear canal may become noticeably narrowed, and pain may worsen during chewing. With pronounced inflammation, purulent discharge and temporary hearing loss may develop. Without treatment, the infection can spread to the auricle and surrounding soft tissues. Recurrence is promoted by regular swimming, humid climates, trauma from cotton swabs, tight in-ear headphones, hearing aids, earwax plugs, eczema, psoriasis, and seborrheic dermatitis. Patients with diabetes or immunodeficiency are at risk of necrotizing otitis externa involving bone and cranial nerves. Recurrent discharge requires exclusion of chronic otitis media and cholesteatoma.

Integrative treatment methods for otitis externa

A topical preparation may be selected only after the external ear canal has been cleaned and the integrity of the eardrum has been confirmed. If there is a perforation, an inserted tympanostomy tube, bloody discharge, severe dizziness, hearing loss, or signs of otitis media, the intra-aural herbal preparations listed below must not be used. If swelling is severe, a topical preparation may not reach the affected skin unless an ear wick is inserted by a specialist.

Jindu Ear Drops are most specifically suited to acute bacterial otitis externa. Chlorhexidine acetate provides local antiseptic activity, while costus, dendrobium, vitex, cyathula, borneol, and other components add anti-inflammatory, antipruritic, anti-edematous, and antifungal effects.

Jindu Ear Drops are used only after discharge has been removed and the eardrum has been confirmed to be intact. The product is contraindicated in cases of perforation, an inserted drainage tube, pronounced weeping dermatitis, allergy to chlorhexidine, camphor, costus, or other ingredients, and in children under six years of age.

Burning, tenderness, hyperemia, increased itching, and allergic contact dermatitis may occur. In the presence of an unrecognized perforation, chlorhexidine entering the middle ear creates a risk of toxic damage to the auditory and vestibular systems. Jindu should not be mixed in the ear canal with other antiseptic, antibiotic, or herbal ear drops.

ABP-153 Oil Infusion is intended primarily for superficial inflammatory and infectious processes affecting the skin, mucous membranes, and cavities. Andrographis, Houttuynia, turmeric, cassumunar ginger, licorice, clove, camphor, eucalyptus, menthol, and borneol provide antimicrobial, antifungal, anti-inflammatory, antipruritic, anti-edematous, and reparative effects.

In diffuse otitis externa, ABP-153 is used intra-aurally or with a sterile turunda only when the eardrum is intact. If there is active discharge, the exudate must first be removed: an oil base applied over pus and desquamated epithelium does not reach the skin evenly and may retain the discharge.

ABP-153 may cause local burning, hyperemia, sneezing if aromatic vapors enter the nasopharynx, increased itching, or an individual allergic reaction. If pain, swelling, or discharge increases, use should be discontinued.

ABP-153 and Jindu Ear Drops are not mixed in the same instillation. They are used as alternative or sequentially prescribed topical preparations depending on the amount of exudate, severity of bacterial inflammation, condition of the epithelium, and stage of the disease. ABP-153D is not required for ordinary superficial otitis externa because the enhanced tissue penetration provided by DMSO does not correspond to the main local therapeutic target.

Chinese goldthread Coptis chinensis in the form of ear drops or another validated topical formulation may be considered as an alternative when bacterial inflammation predominates. Berberine and related alkaloids provide antimicrobial, anti-inflammatory, and antibiofilm effects.

Topical Coptis preparations must not be used if the eardrum is perforated, a drainage tube has been inserted, or the condition of the middle ear is unknown. Burning, pain, hyperemia, increased dryness, and contact reactions may occur on damaged sensitive skin.

Coptis should not automatically be combined with Jindu Ear Drops or other topical antimicrobial formulations. Simultaneous use of several active formulas increases the chemical burden on the epithelium, makes it more difficult to identify the cause of an adverse reaction, and does not guarantee a stronger clinical effect.

Baikal skullcap Scutellaria baicalensis is more appropriate when inflammation, itching, an eczematous component, or a suspected fungal complication is pronounced. Baicalin, baicalein, and wogonin are involved in the regulation of inflammatory mediators and have antimicrobial, antifungal, and antibiofilm activity.

An otic formulation of skullcap is contraindicated in cases of eardrum perforation, a foreign body, an inserted tympanostomy tube, and purulent otitis media. Local burning, dryness, and allergic contact reactions may occur. Unless there is a separate clinical indication, it should not be layered on top of ABP-153, Jindu, or Coptis.

If systemic anti-inflammatory support is required, dry skullcap extract may be taken orally. Possible effects include drowsiness, slowed responsiveness, dizziness, reduced blood pressure, and muscle weakness. Caution is required in liver disease and when used together with sedatives, antihypertensive medications, anticoagulants, and antiplatelet agents.

Black seed Nigella sativa is primarily appropriate during the recovery stage, for dryness, scaling, eczematous inflammation, and prevention of recurrent episodes after swimming. Thymoquinone and other lipophilic components provide anti-inflammatory, antimicrobial, and barrier-restoring effects.

An oil-based otic formulation of Nigella sativa is considered an alternative to other topical oil preparations and should not automatically be used simultaneously with ABP-153. It should not be used topically in the presence of active purulent discharge, otitis media, pronounced weeping, or suspected perforation.

Oral Nigella sativa extract may be appropriate for recurrent otitis externa associated with allergic dermatitis, diabetes mellitus, or other metabolic factors. Possible adverse effects include dyspepsia, diarrhea, headache, reduced blood pressure and blood glucose levels, and allergic reactions. Concomitant use with antihypertensive and glucose-lowering medications, anticoagulants, and antiplatelet agents must be taken into account.

Five Root Compound anti-inflammatory mixture may be used systemically for pronounced inflammatory pain, swelling, and tenderness of the ear canal. Harrisonia, Capparis, Clerodendrum, Ficus racemosa, Tiliacora, and other components provide anti-inflammatory, analgesic, and antioxidant effects.

Five Root Compound does not replace local cleaning, eradication of the pathogen, or restoration of ear canal patency. In moderate itching without pronounced pain or swelling, adding a systemic anti-inflammatory formula is not necessary. Individual hypersensitivity and dyspeptic reactions are possible; concomitant use with other systemic anti-inflammatory, antihypertensive, and coagulation-modifying agents should be taken into account.

Antipyretic Compound is considered only when fever, chills, and systemic intoxication are confirmed. It is usually not required for localized otitis externa because marked fever is not typical of a superficial process.

An elevated body temperature warrants exclusion of otitis media, spread of infection to the auricle and surrounding tissues, mastoiditis, or necrotizing otitis externa. Antipyretic therapy should not mask persistent systemic infection. The formula is contraindicated in cases of individual intolerance to its components; suspected dengue fever and severe liver disease require separate medical evaluation.

The advantage of rationally selected topical herbal formulations lies in their direct effect on the skin of the ear canal while minimizing systemic burden on the liver, kidneys, gastrointestinal tract, cardiovascular system, and nervous system. They do not create the risks typical of systemic fluoroquinolones, such as tendon damage, peripheral nerve injury, glycemic disturbances, and multiple drug interactions.

Natural origin does not exclude burning, contact dermatitis, allergy, or irritation of damaged epithelium. Topical preparations should therefore be selected according to the clinical phenotype: Jindu for a predominantly acute bacterial process, ABP-153 for superficial mixed inflammation and epithelial recovery, Coptis as an alternative antimicrobial approach, skullcap for a pronounced inflammatory-eczematous or fungal component, and Nigella sativa primarily during the recovery stage. Several topical agents should not be layered on top of one another without a clear rationale.

Frequently asked questions

Can I simply shake the water out of my ear? Once pain, swelling, and discharge have appeared, the problem is no longer related only to retained water. Jumping, vigorous shaking of the head, and inserting foreign objects into the ear canal may worsen skin trauma and push the discharge deeper.

Can I use earplugs? During active inflammation, tight in-ear earplugs retain moisture, impair ventilation, and additionally traumatize the ear canal. They should be used again only after pain, discharge, and swelling have disappeared and the skin has completely recovered.

Why did I feel worse after using ear drops? Possible causes include chemical irritation, allergic contact dermatitis, fungal replacement of the bacterial flora, pathogen resistance, an inappropriate choice of medication, or entry of a potentially ototoxic substance through a damaged eardrum.

When can I swim again? After pain, discharge, and swelling have completely resolved, the normal width of the ear canal has been restored, and, after a severe or recurrent episode, following a follow-up examination by an otorhinolaryngologist.

What you need to know about standard modern medical protocols

The basis of treatment for acute otitis externa is examination of the external ear canal and eardrum, careful removal of pus, exudate, desquamated epithelium, and other material by a specialist, followed by topical therapy. Without cleaning, medicated drops are distributed unevenly and do not adequately contact the affected skin. If swelling is pronounced, an ENT specialist may insert an ear wick to allow medication to reach a severely narrowed ear canal. Self-insertion of cotton swabs, metal objects, or tightly packed turundas traumatizes the skin, pushes discharge deeper, and increases the risk of infection spreading.

Antiseptic and acidifying solutions may be used for a mild superficial process only after the integrity of the eardrum has been confirmed. Acetic acid, alcohol-containing solutions, and other acidic preparations can cause intense burning, chemical irritation, excessive drying, cracking, and increased pain. In the presence of pronounced erosions or an incorrect concentration, chemical damage to the epithelium is possible.

Antiseptic and acidifying agents should not be instilled without medical supervision in the presence of purulent, bloody, or watery discharge, suspected perforation, an inserted tympanostomy tube, previous middle-ear surgery, severe dizziness, or sudden hearing loss. Alcohol, acids, and certain antiseptics entering the middle ear may cause severe pain, inflammation of the middle-ear mucosa, vestibular disturbances, and toxic damage to structures of the auditory system.

Fluoroquinolone ear drops containing ciprofloxacin or ofloxacin are used against the most likely bacterial pathogens responsible for otitis externa. Systemic absorption is generally low, but these medications may cause local burning, itching, pain, dryness, irritation, contact dermatitis, and allergic reactions. Absorption increases when the skin is damaged and with prolonged use.

Repeated or unjustified use of fluoroquinolone drops suppresses susceptible bacterial flora and selects resistant strains. As a result, subsequent episodes of infection may respond less effectively to treatment. At the same time, the normal microbiota of the ear canal is disrupted, creating conditions for fungal superinfection. Reduced pain while using the drops does not rule out a persistent abscess, middle-ear involvement, or spread of the infection to surrounding tissues.

Combinations of a topical antibiotic with a glucocorticosteroid simultaneously suppress susceptible bacterial flora, swelling, and inflammatory pain. The corticosteroid rapidly reduces itching and hyperemia but does not improve eradication of a resistant pathogen. It suppresses the local immune response, may mask progression of the infection, delay epithelialization of erosions, and promote fungal growth.

Prolonged or repeated use of the hormonal component can lead to thinning of the ear canal skin, increased fragility, telangiectasia, fissures, and secondary bacterial or fungal infection. Rapid visible improvement with a steroid may sometimes create a false impression of recovery while the infection persists.

Preparations containing aminoglycoside antibiotics such as neomycin, gentamicin, framycetin, and others must not be used without confirmation that the eardrum is intact. If they enter the middle ear, they can irreversibly damage the hair cells of the cochlea and vestibular apparatus. Consequences may include permanent hearing loss, tinnitus, dizziness, and impaired balance and coordination.

Neomycin relatively often causes allergic contact dermatitis. Sensitization manifests as increased itching, swelling, weeping, redness, and scaling and may mistakenly be interpreted as worsening of the infection itself. Repeated administration after an allergy has developed may cause a more pronounced reaction.

Systemic antibiotics are not standard treatment for uncomplicated otitis externa because topical preparations achieve a substantially higher concentration in the ear canal. Oral or intravenous treatment is considered when inflammation spreads to the auricle and surrounding tissues, in the presence of fever or other systemic manifestations, diabetes mellitus, immunodeficiency, inability to provide adequate topical treatment, or suspicion of a deep necrotizing process.

Systemic antibiotics can cause nausea, abdominal pain, diarrhea, candidiasis, drug-induced rash, anaphylaxis, toxic liver and kidney injury, suppression of hematopoiesis, and numerous drug interactions. Some medications can provoke Clostridioides difficile infection with profuse diarrhea, dehydration, toxic megacolon, intestinal perforation, sepsis, and possible death.

Systemic fluoroquinolones may be prescribed when Pseudomonas infection is suspected. They can cause tendon inflammation and rupture, irreversible peripheral neuropathy, seizures, anxiety, insomnia, confusion, hallucinations, glycemic disturbances, QT interval prolongation, and dangerous ventricular arrhythmias. The risk of tendon injury is particularly high in older adults, patients with renal impairment, and those taking systemic glucocorticosteroids at the same time.

In patients with diabetes mellitus, severe immunodeficiency, and intense persistent pain, necrotizing otitis externa must be ruled out. Attempting to treat it with ear drops alone may delay diagnosis of infection spreading to the temporal bone, skull base, and cranial nerves.

Paracetamol is used to reduce pain and fever but does not suppress bacterial infection. Its main danger is dose-dependent hepatic necrosis. Exceeding the total dose, combining several combination products containing paracetamol, regular alcohol consumption, fasting, and liver disease can lead to acute liver failure, impaired coagulation, encephalopathy, coma, the need for liver transplantation, and death.

Nonsteroidal anti-inflammatory drugs such as ibuprofen, naproxen, ketoprofen, and others reduce inflammatory pain but may cause erosions, ulcers, massive gastrointestinal bleeding, and perforation of the stomach or intestine. Severe bleeding can develop without pronounced warning symptoms.

NSAIDs reduce renal blood flow, promote sodium and fluid retention, increase blood pressure, and may cause edema, acute kidney injury, and decompensation of heart failure. Bronchospasm, anaphylaxis, liver injury, severe skin reactions, and an increased risk of cardiovascular thrombotic complications are also possible.

Without medical supervision, NSAIDs are undesirable in patients with peptic ulcer disease, gastrointestinal bleeding, renal impairment, decompensated heart failure, coagulation disorders, NSAID-induced bronchospasm, and pregnancy. Concomitant use with anticoagulants, antiplatelet agents, systemic glucocorticosteroids, and certain antidepressants sharply increases the risk of bleeding.

A reliable percentage of complete recovery and absence of recurrence over a two-year period has not been established for otitis externa. The outcome depends on whether provoking factors persist, including regular water exposure, trauma to the ear canal, use of in-ear headphones and earplugs, dermatitis, fungal infection, diabetes mellitus, and improper use of ear drops.

Simultaneous or sequential use of antiseptics, acidic solutions, several antibiotics, glucocorticosteroids, systemic antibacterial medications, and NSAIDs may cause chemical damage to the skin, contact sensitization, disruption of the normal flora, fungal superinfection, ototoxic hearing loss, drug-induced hepatitis, renal failure, gastrointestinal bleeding, and development of resistant microflora. Alternative integrative approaches based on rationally selected topical and systemic herbal formulas allow treatment to target infectious inflammation, pain, swelling, and epithelial recovery and generally do not cause the same degree of aggressive local and systemic injury as prolonged or unjustifiably combined use of chemically synthesized medications.

Why dosages and treatment duration are not provided in this article

Otitis externa may be bacterial, fungal, eczematous, or mixed and may be accompanied by varying degrees of swelling, discharge, and skin damage. Before choosing a treatment regimen, it is necessary to assess the condition of the eardrum, patency of the ear canal, nature of the discharge, age, body weight, presence of diabetes, immunodeficiency, liver and kidney disease, allergies, and medications already being used.

A universal regimen may be insufficient, excessive, or dangerous. Choosing ear drops independently in the presence of discharge is particularly unacceptable because the discharge may be associated with eardrum perforation. The article therefore describes treatment approaches but does not replace otoscopy and an individualized clinical and pharmacological assessment.

If necessary, you may ask a short question in the comments to this article, while in more complex cases you may schedule a consultation with a clinical pharmacologist specializing in integrative medicine via the following link: https://asiabiopharm.com/konsultaciii