Swimmer’s Ear in Kids: Signs, Drops & Prevention

How to tell an outer-ear infection from a middle-ear infection, what treatment works, and how to prevent it in Texas swim season

In North Texas, swim season runs long. Between neighborhood pools, swim team, and lake weekends, many children are in the water from May well into September. That makes swimmer’s ear one of the most common ear problems I see in summer. It is very treatable, but it is often confused with a middle-ear infection and sometimes treated with oral antibiotics it does not need. As a fellowship-trained pediatric ENT in Frisco, I want parents to know how to recognize it, what the evidence says about treatment, and when a painful ear needs more than a bottle of drops.

Key takeaways

• Swimmer’s ear (acute otitis externa) infects the skin lining the ear canal, outside the eardrum. A middle-ear infection (acute otitis media) is behind the eardrum. They are treated differently.
• The giveaway is pain when the outer ear is touched: pressing on the small flap in front of the ear canal or gently pulling the ear makes swimmer’s ear hurt more.
• Prescription ear drops are the first-line treatment. National guidelines from the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) recommend against oral antibiotics for uncomplicated swimmer’s ear.
• Pain control matters. Swimmer’s ear can be intensely painful, and treating the pain is part of treating the infection.
• If your child has ear tubes or a hole in the eardrum, only certain drops are safe. Tell the clinician before any drops are prescribed.
• Improvement should start within 48 to 72 hours. If it does not, the ear should be rechecked.
• Prevention is mostly about keeping ear canals dry and leaving earwax alone.

What swimmer’s ear is, and why water causes it

The ear canal is a short tunnel of skin that runs from the opening of the ear to the eardrum. Its lining is protected by a thin, slightly acidic, water-repellent layer of earwax. Long or repeated soaking washes that layer away and leaves the skin damp and swollen. Scratching, cotton swabs, or earbuds can then create tiny breaks in the skin, and bacteria take hold. The AAO-HNS guideline notes that nearly all (about 98 percent) acute otitis externa in North America is bacterial, most often Pseudomonas aeruginosa and Staphylococcus aureus.

Bathing, sweating, eczema, and anything that traps moisture can contribute, but water exposure and warm, humid weather are the classic triggers. A Centers for Disease Control and Prevention (CDC) analysis estimated about 2.4 million US health care visits for swimmer’s ear in a single year, with the highest visit rates in children ages 5 to 14, a peak in summer, and the highest regional rate in the South.

Swimmer’s ear or a middle-ear infection?

When a parent says “my child has an ear infection,” the first job is to figure out which part of the ear is involved. The history and a look with an otoscope usually settle it.

The “tug test” is not perfect, but it is useful. The AAO-HNS guideline describes tenderness of the tragus (the small flap in front of the ear canal) when it is pushed, or of the outer ear when it is pulled, as a hallmark of swimmer’s ear, often out of proportion to how the canal looks. A child with a middle-ear infection usually does not flinch when you touch the outer ear.

There is one important overlap. A child with ear tubes, or with an eardrum that has ruptured during a middle-ear infection, can have pus draining into the canal, which irritates the canal skin and looks like swimmer’s ear. That distinction matters because it changes which drops are safe. My post on understanding ear infections and my page on ear infections in children explain middle-ear infections in more detail.

Common symptoms

• Itching inside the ear, often the first sign
• Ear pain that builds over a day or two and gets worse with chewing, touching the ear, or lying on that side
• A full or plugged feeling, and muffled hearing on that side if the canal swells shut
• Clear, yellow, or cloudy drainage
• Redness and swelling of the canal opening

What treatment actually works

The AAO-HNS guideline on acute otitis externa, updated in 2014, applies to children 2 years and older and adults. Its main recommendations are clear and parent-friendly.

1. Treat the pain

Swimmer’s ear can hurt far more than it looks. The guideline strongly recommends assessing pain and treating it according to severity. For most children, acetaminophen or ibuprofen works well, dosed by your child’s weight per your pediatrician’s advice or the package label.

2. Use prescription ear drops, not oral antibiotics

Topical drops put a high concentration of medicine exactly where the infection is. A Cochrane systematic review of randomized trials concluded that topical treatment alone is effective for uncomplicated acute otitis externa and that, in most cases, the specific type of drop made little difference to cure rates. Antibiotic-steroid drops were much more effective than placebo drops.

The guideline makes a strong recommendation against oral antibiotics as the first treatment for uncomplicated swimmer’s ear. Oral antibiotics are reserved for infection that has spread beyond the ear canal, such as redness and swelling of the outer ear or the skin around it, or for patients with specific risk factors, such as diabetes or a weakened immune system. Using them when drops would work adds side effects and antibiotic resistance without faster healing.

Drops are usually used for 7 to 10 days. The guideline notes that the optimal duration has not been firmly established, so follow the instructions on your child’s prescription.

3. Get the drops where they need to go

Drops only work if they reach the infected skin. A few practical tips:

• Have an adult put the drops in, after warming the bottle in your hands so cold drops do not cause dizziness.
• Have your child lie down with the sore ear facing up, fill the canal, and gently press the tragus a few times to move the drops in.
• Keep your child lying still for a few minutes before sitting up.

If the canal is badly swollen or packed with debris, the drops cannot get in. In the office, I can gently clean the canal under magnification (called aural toilet) and, if needed, place a wick, a small compressed sponge that expands with the drops and carries medicine down the canal. Wicks usually fall out on their own or are removed after a few days.

4. Choose drops that are safe for your child’s eardrum

If your child has ear tubes, a known hole in the eardrum, or an eardrum the clinician cannot see well enough to be sure it is intact, the guideline recommends a non-ototoxic drop, meaning one that does not risk harming the inner ear. In practice, that usually means a fluoroquinolone antibiotic drop, with or without a steroid. Some older drops contain aminoglycoside antibiotics or alcohol, which should not be used when the eardrum is open. Always mention ear tubes or past eardrum problems before any drops are prescribed. For more on tubes, see my pages on ear tubes in Frisco and ear tubes in McKinney.

5. Recheck if it is not getting better

Most children feel better within 48 to 72 hours of starting drops. If your child does not, the guideline recommends a recheck to confirm the diagnosis and look for other causes. Common reasons for slow improvement include drops not reaching the canal, a canal blocked by swelling or debris, a skin reaction to an ingredient in the drops, an underlying middle-ear infection, or a fungal infection.

Fungal infections and other look-alikes

Fungal involvement is uncommon in a first episode of swimmer’s ear but more likely after repeated or prolonged antibiotic drops. A fungal canal infection (otomycosis) tends to itch more than hurt and often shows white, gray, or dark debris. The usual causes are Aspergillus and Candida, and treatment focuses on careful cleaning of the canal plus an antifungal medicine. Other conditions that can mimic swimmer’s ear include eczema of the ear canal, a small boil (furuncle) near the canal opening, an object in the ear, and drainage from a middle-ear infection. A rare, serious, deeper form of outer-ear infection occurs mainly in older adults with diabetes or weakened immune systems and is uncommon in otherwise healthy children.

Prevention for Texas swim season

The guideline’s prevention advice centers on protecting the canal’s natural defenses. Here is how I translate it for families:

• Leave earwax alone. It repels water and helps keep the canal slightly acidic. Do not use cotton swabs, fingers, or other objects to clean or dry the canal; scratching the canal is a common trigger.
• Get the water out after swimming. Tilt the head to each side, dry the outer ear with a towel, and, if needed, use a hair dryer on the lowest, coolest setting held well away from the ear. My post on how to get water out of your ears covers the safe techniques in detail.
• Consider swim earplugs or a swim cap for children who get swimmer’s ear repeatedly. Well-fitted plugs are the simplest way to keep water out.
• Drying or acidifying drops, only with a healthy eardrum. Over-the-counter drying drops, or acidifying drops used before or after swimming, can help children who get swimmer’s ear often. They are not for children with ear tubes, a hole in the eardrum, or a currently painful ear. Ask your child’s doctor before starting them.
• Treat eczema and other skin conditions of the ear, which make the canal more vulnerable.
• Wait until the ear is cleared before swimming again. Keep the infected ear dry during treatment. Once the infection has been treated and your child’s pediatrician or ENT has rechecked the ear and cleared it, your child can return to swimming.

For children with ear tubes, the AAO-HNS tympanostomy tube guideline recommends against routine water precautions (earplugs, headbands, or avoiding swimming) for most children. Your child’s surgeon may advise otherwise in specific situations. If a child with tubes develops drainage, that guideline strongly recommends antibiotic ear drops alone, without oral antibiotics, for uncomplicated cases.

Red flags: when a painful ear needs prompt attention

Seek same-day care, or go to the emergency department, if your child has:

• Redness and swelling spreading onto the outer ear, the cheek, or behind the ear
• Swelling that pushes the ear forward or outward, or tenderness of the bone behind the ear
• A high fever, or a child who looks very ill
• Severe pain that is not controlled by acetaminophen or ibuprofen
• Facial weakness, a drooping mouth or eyelid on one side, dizziness, or a sudden drop in hearing
• An object, insect, or button battery that may be in the ear

When to see a pediatric ENT

Your pediatrician can manage most first episodes of swimmer’s ear. A pediatric ENT visit is worthwhile if:

• Swimmer’s ear keeps coming back, especially during each swim season
• The canal is too swollen or full of debris for drops to reach the infection, and cleaning or a wick is needed
• Symptoms are not improving after 48 to 72 hours of drops, or have not cleared after a full course
• A fungal infection is suspected
• Your child has ear tubes, a hole in the eardrum, or a history of ear surgery
• There is drainage that keeps returning, or hearing has not returned to normal after the infection clears. My page on pediatric hearing loss explains hearing evaluation in children.
• Your child has eczema of the ear canal, diabetes, or an immune problem that complicates treatment

From my research and practice

Two papers I co-authored bear on how I treat ear infections. In 2007, colleagues and I published a retrospective review of head and neck infections cultured by our otolaryngology service at a coastal tertiary medical center between 1999 and 2004. Community-acquired methicillin-resistant Staphylococcus aureus (MRSA) rose from 21 percent to 64 percent of those infections over five years, and the isolates were resistant to common first-line antibiotics such as cefazolin and penicillin. That study did not focus on swimmer’s ear, but it is one reason I culture drainage when an ear infection spreads beyond the canal or does not respond to the first treatment.

In 2014, I co-authored a review of 46 US malpractice cases involving hearing loss attributed to medications. Antibiotics, particularly the aminoglycoside class, were the most commonly cited drugs, and failure to choose a less toxic medication was one of the reasons cited in cases decided for the patient. That review covered medications in general, not ear drops specifically, but it reinforces a principle the guideline also stresses: when the eardrum may not be intact, choose a drop that will not harm the inner ear. The full list of my work is on my publications and research page.

Frequently asked questions

How can I tell whether my child has swimmer’s ear or a regular ear infection?

Swimmer’s ear usually follows water exposure and hurts more when you press on the small flap in front of the ear canal or gently pull the ear. A middle-ear infection usually comes with or after a cold, may cause fever, and does not usually hurt more when the outer ear is touched. A look with an otoscope confirms which one it is.

Does my child need oral antibiotics for swimmer’s ear?

Usually not. The AAO-HNS guideline recommends prescription ear drops as the first treatment for uncomplicated swimmer’s ear and recommends against oral antibiotics unless the infection has spread beyond the ear canal or the child has specific risk factors. Pain relief and correct use of the drops are the other keys to recovery.

Are ear drops safe if my child has ear tubes?

Some are and some are not. If your child has ear tubes or a hole in the eardrum, the guideline recommends a non-ototoxic drop, usually a fluoroquinolone antibiotic drop, and avoiding drops that could harm the inner ear. Always tell the clinician about tubes before drops are prescribed.

Can my child swim while being treated for swimmer’s ear?

Not during treatment. Keep the infected ear dry until the course of drops is finished and your child’s pediatrician or ENT has rechecked the ear and cleared it, because water in a healing canal can slow recovery and set up another infection. Once the ear is cleared, your child can go back to swimming. If swimmer’s ear keeps recurring, earplugs or a swim cap can help.

Should my child use drying drops after every swim?

Not every child needs them. Drying or acidifying drops can help children who get swimmer’s ear often, but only if the eardrum is intact and there are no ear tubes. Ask your child’s doctor before starting them, and do not use them in an ear that is already painful or draining.

References

1. Rosenfeld RM, Schwartz SR, Cannon CR, et al. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck Surg. 2014;150(1 Suppl):S1–S24. doi:10.1177/0194599813517083
2. Kaushik V, Malik T, Saeed SR. Interventions for acute otitis externa. Cochrane Database Syst Rev. 2010;(1):CD004740. doi:10.1002/14651858.CD004740.pub2
3. Centers for Disease Control and Prevention. Estimated burden of acute otitis externa: United States, 2003–2007. MMWR Morb Mortal Wkly Rep. 2011;60(19):605–609. PMID:21597452
4. Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics. 2013;131(3):e964–e999. doi:10.1542/peds.2012-3488
5. Rosenfeld RM, Tunkel DE, Schwartz SR, et al. Clinical practice guideline: tympanostomy tubes in children (update). Otolaryngol Head Neck Surg. 2022;166(1 Suppl):S1–S55. doi:10.1177/01945998211065662
6. Vennewald I, Klemm E. Otomycosis: diagnosis and treatment. Clin Dermatol. 2010;28(2):202–211. doi:10.1016/j.clindermatol.2009.12.003
7. Bothwell NE, Shvidler J, Cable BB. Acute rise in methicillin-resistant Staphylococcus aureus infections in a coastal community. Otolaryngol Head Neck Surg. 2007;137(6):942–946. doi:10.1016/j.otohns.2007.09.013
8. Ruhl DS, Cable BB, Martell DW. Medication associated with hearing loss: 25 years of medical malpractice cases in the United States. Otolaryngol Head Neck Surg. 2014;151(3):431–437. doi:10.1177/0194599814536850

If your child’s ear pain is not settling, or swimmer’s ear keeps coming back every summer, I’m happy to take a look. You can contact my office to schedule a visit in Frisco or at the McKinney office of ENT and Allergy Centers of Texas.