REVIEW ARTICLE

Ear Problems in Swimmers

Mao-Che Wang1,4, Chia-Yu Liu2,4, An-Suey Shiao1,4, Tyrone Wang3,4*
1
Department of Otolaryngology, Taipei Veterans General Hospital, 2Department of Otolaryngology,
3
Taoyuan Veterans Hospital, Department of Otolaryngology, Taipei Municipal Yang-Ming Hospital,
4
and National Yang-Ming University School of Medicine, Taipei, Taiwan, R.O.C.

Acute diffuse otitis externa (swimmers ear), otomycosis, exostoses, traumatic eardrum perforation, middle ear
infection, and barotraumas of the inner ear are common problems in swimmers and people engaged in aqua activities.
The most common ear problem in swimmers is acute diffuse otitis externa, with Pseudomonas aeruginosa being
the most common pathogen. The symptoms are itching, otalgia, otorrhea, and conductive hearing loss. The treatment
includes frequent cleansing of the ear canal, pain control, oral or topical medications, acidification of the ear canal,
and control of predisposing factors. Swimming in polluted waters and ear-canal cleaning with cotton-tip applicators
should be avoided. Exostoses are usually seen in people who swim in cold water and present with symptoms of
accumulated debris, otorrhea and conductive hearing loss. The treatment for exostoses is transmeatal surgical removal
of the tumors. Traumatic eardrum perforations may occur during water skiing or scuba diving and present with symptoms
of hearing loss, otalgia, otorrhea, tinnitus and vertigo. Tympanoplasty might be needed if the perforations do not
heal spontaneously. Patients with chronic otitis media with active drainage should avoid swimming, while patients
who have undergone mastoidectomy and who have no cavity problems may swim. For children with ventilation tubes,
surface swimming is safe in a clean, chlorinated swimming pool. Sudden sensorineural hearing loss and some degree
of vertigo may occur after diving because of rupture of the round or oval window membrane. [J Chin Med Assoc
2005;68(8):347352]

Key Words: ear, exostoses, otitis externa, swimming

Introduction problems related to swimming and other aqua

activities.
Swimming and other aqua activities are important
human activities. Millions of people swim, dive,
scuba dive, surf or boat, either professionally or External Ear
recreationally, in different depths of water in swimming
pools, ponds, rivers, lakes and oceans. When a persons Acute diffuse otitis externa
ears are exposed directly to water without protection, Otitis externa can be inflammatory, eczematoid, or
the external ear canal and tympanic membrane can be seborrheic in nature. Inflammatory otitis externa can
contaminated and pressure can easily be transmitted be subclassified into the following types: acute localized,
into the middle and inner ear and cause several acute diffuse, and chronic diffuse. Acute diffuse otitis
problems, especially infections and trauma. The externa (swimmers ear) and otomycosis are the most
external, middle, and inner ear are all susceptible to common problems in swimmers.
these problems. This article discusses ear problems The external ear comprises the auricle and external
that are frequently encountered at otolaryngology ear canal. The average length of the adult external
clinics, including external, middle, and inner ear auditory canal is 2.5 cm. Because of the oblique

*Correspondence to: Dr. Tyrone Wang, Department of Otolaryngology, Taipei Municipal Yang-Ming Hospital, 105,
Yu-Sheng Street, Shih-Lin, Taipei 111, Taiwan, R.O.C.
E-mail: [email protected]
Received: November 19, 2004
Accepted: March 23, 2005

J Chin Med Assoc August 2005 Vol 68 No 8 347

2005 Elsevier. All rights reserved.
 M.C. Wang, et al

position of the tympanic membrane, the favorable. Water quality is related to otitis externa.
posterosuperior part of the canal is about 6 mm shorter The more polluted the water, the easier otitis externa
5,79
than the anteroinferior portion. The lateral 40% of the may occur. Ear problems can be transmitted via
external auditory canal is cartilaginous and contains a recreational contact with marine waters contaminated
thin layer of subcutaneous tissue between the skin and with sewage. Fecal coliform exposure may be predictive
cartilage. The medial 60% is osseous, formed primarily of ear ailments: an estimated threshold for infection
by the tympanic ring, and contains very scant soft was a bather exposure level of > 100 fecal coliforms per
tissue among the skin, periosteum and bone. The 100 mL of water.10
junction of the cartilaginous and bony portions of the The very early symptom of otitis externa is itching;
canal is a narrowed section termed the isthmus. The aural discharge, otalgia and tenderness then develop.
external ear canal is lined with keratinized, stratified Accumulation of discharge and debris in the external
squamous epithelium. There are hair follicles and ear canal may lead to aural fullness and conductive
sebaceous and apocrine glands that produce cerumen, hearing loss.
which has an acid reaction and maintains the normal Simple manipulation of the pinna or pushing the
canal pH of 5. This acid environment inhibits bacterial tragus may elicit severe pain in acute diffuse otitis
and fungal growth. The lipid content of cerumen externa. The external ear canal and tympanic membrane
protects the surface of the squamous epithelium and should be examined carefully with an otoscope or
pilosebaceous units and prevents maceration and microscope under good illumination. The examination
breakdown of the epithelium. It thus provides both a reveals a swollen and edematous canal. Initially, the
chemical and mechanical protective barrier to infection. canal is often filled with copious serous discharge,
The normal external auditory canal has a flora that which then turns into a foul-smelling purulent discharge
principally includes Staphylococcus albus, S. epidermidis, with debris causing occlusion. If any discharge is noted
Corynebacterium spp. and small quantities of S. aureus on examination, ear swabs should be obtained for
1,2
and Streptococcus viridans. bacterial culture and sensitivity tests to guide antibiotic
Heat and humidity cause swelling of the stratum use. Lymphadenopathy can occur in postauricular,
corneum in the skin. Introduction of extraneous subauricular and, occasionally, periauricular parotid
moisture from swimming or bathing increases areas. Sometimes, inflammation may spread to the
maceration of the canal skin, encourages destruction auricle and involve the entire auricle.
of the protective barrier, and creates a condition Acute diffuse otitis externa should be differentiated
favorable to bacterial growth. These changes may also from other forms of otitis externa, such as herpes
cause itching in the external auditory canal, thus zoster oticus, or eczematoid, seborrheic or malignant
adding the possibilities of scratching and subsequent forms. Patients with swimmers ear have a history of
infection. water exposure and sometimes may also have a history
It is well known that the predominant pathogen in of trauma to the ear canal. Herpes oticus is herpes
swimmers ear is Pseudomonas aeruginosa. Other zoster infection with ear-canal and auricular
organisms involved are Proteus vulgaris, Escherichia involvement. Vesicles and serous discharge are noted
coli, S. aureus, S. epidermidis, streptococci, in the ear canal and auricle. Eczematoid otitis externa
diphtheroids, Enterobacter aerogenes, Klebsiella includes various hypersensitivity reactions of the canal
pneumoniae and Citrobacter spp.2 skin due to contact dermatitis or neurodermatitis.
The risk of otitis externa is reported to be Seborrheic otitis externa is associated with seborrheic
approximately 5 times greater in swimmers than dermatitis of other regions, particularly the scalp. The
nonswimmers, and that of otalgia is reported to be lesions comprise yellowish, greasy scaling of the ear
3
2.4 times greater in swimmers than nonswimmers. canal. Malignant (necrotizing) otitis externa, which is
Besides ear problems, swimmers and people who characterized by severe otalgia, is a type of temporal
enjoy aqua activities may develop gastrointestinal, bone osteomyelitis. The most common pathogen is
respiratory, dermatologic, and ear, nose and throat P. aeruginosa, and generally, only immunocompromised
infections. 46 The duration and type of exposure, hosts, such as patients with diabetes mellitus, are
concentration of pathogens, and host immunity affected. The treatment is aggressive parenteral
determine the risk of infection. Pathogens undetectable antibiotics against P. aeruginosa and control of the
by conventional methods may remain viable in marine underlying disease. Acute diffuse otitis externa must
waters, and both plankton and marine sediments may also be differentiated from carcinoma involving the
serve as reservoirs for pathogenic organisms, which external ear canal. It is often mistaken at the earliest
can emerge to become infective when conditions are stage for infection and treated inappropriately.

348 J Chin Med Assoc August 2005 Vol 68 No 8

 Ear problems in swimmers

The management of acute diffuse otitis externa dried using a hair dryer after each period of swimming.
includes frequent inspection and cleansing of the ear Ear-canal cleaning with cotton-tip applicators should
15
canal, control of pain, use of appropriate medications, be avoided as it will traumatize the canal skin and
either oral or topical, acidification of the ear canal, and compromise the mechanical barrier of the canal, thus
control of predisposing factors. Cleansing the ear increasing the possibility of otitis externa.
canal is perhaps the single most important aspect of
treatment. Frequent inspection and drying of the Otomycosis
canal are also important. Cleansing can be done by Fungal infection is also a common external ear problem
irrigation, gentle suction, and gentle application of in swimmers that can be facilitated by heat and
cotton swabs, under direct visualization. Removal of moisture.16 Physical examination may show swelling
discharge and debris can facilitate the application of and hyperemia of the canal skin, and fungal hyphae or
topical medications. Drying of the ear canal can be characteristic cheese-like grayish debris in the canal.
done with 70% alcohol. Acute diffuse otitis externa The treatment is similar to that for acute diffuse otitis
caused by edema and inflammation can be very painful, externa, including frequent cleansing, preventing
and can be controlled by nonsteroidal anti- moisture, and drying the canal. Topical application
inflammatory drugs, or narcotics such as codeine or of antifungal drugs is also helpful, but recurrence is
hydrocodone. The short-term use of corticosteroids common.
can be useful for pain control if not contraindicated.
Together with cleansing, topical medication is Exostoses
usually effective as an initial treatment, and can be The most common benign bony tumors of the external
administered directly or by a wick. Acidifying agents ear canal are exostoses and osteomas. Prolonged
can acidify the canal environment to inhibit bacterial exposure to cold water in activities such as swimming,
and fungal growth. Topical corticosteroids can reduce surfing or diving not only increases the risk of
inflammation, edema and itching, and antibiotic developing exostoses but also increases the severity of
ointment can attack specific organisms. Neomycin is the condition.1719 The symptoms of exostoses include
effective against Proteus and Staphylococcus spp., and debris accumulation in the ear canal, otorrhea secondary
polymyxin is effective against Pseudomonas spp. to otitis externa, and conductive hearing loss. The
Chloramphenicol is effective against Bacteroides fragilis, bony tumor may block the ear canal and obstruct
an anerobe that is less common. Chemical agents such cleansing of the ear canal medial to the tumor. The
as aqueous gentian violet 2% and silver nitrate 10% are accumulation of debris medial to the tumor increases
bactericidal and may be applied directly to canal skin. the risk of infection leading to otorrhea. The tumor
Systemic antibiotics should be used in patients with itself and the accumulated debris also cause conductive
lymphadenopathy, in patients taking systemic hearing loss. Exostoses should be differentiated from
corticosteroids, and in immunocompromised patients, osteoma. Exostoses are usually bilateral, broad-based
such as those with diabetes. The initial, oral antibiotic lesions that arise from the medial aspect of the bony
therapy may be an empiric selection against common ear canal near the tympanic annulus, along the tym-
offending pathogens; subsequently, a change to panomastoid and tympanosquamous suture lines. In
appropriate therapy is required based on culture and contrast, osteomas are typically solitary and unilateral.
sensitivity results. Patients in whom the condition is These pedunculated bony tumors are less common
severe may require parenteral antibiotic therapy against than exostoses and are found in the outer half of the ear
P. aeruginosa. canal.20 The treatment for exostoses is transmeatal
For the prevention of acute diffuse otitis externa, surgical removal.21
swimming avoidance is effective, but is impractical for
swimmers or participants in aqua activities. Various
protective devices, including commercial rubber or Middle Ear
silicon ear plugs, cotton wool coated with paraffin jelly
or Vaseline, and swimming caps, are advised and may Traumatic eardrum perforation
be useful.2,1113 Swimming in clean water, such as in a Swimming and water sports, especially water skiing
chlorinated swimming pool, or at non-polluted and scuba diving, may lead to traumatic eardrum
beaches, rivers or lakes, will decrease the risk of infection. perforation, which is one of the principal types of non-
Keeping the ear canal dry may also be helpful, since the explosive blast injury to the ear.22 Individuals with
incidence of otitis externa can be minimized by previous recurrent otitis media, atrophic scarring of
eliminating moisture in the canal.14 The ear canal can be the tympanic membrane, and poor Eustachian tube

J Chin Med Assoc August 2005 Vol 68 No 8 349

 M.C. Wang, et al

function, are predisposed to traumatic eardrum otolaryngologists were not confident with their
perforation. In scuba diving, tympanic membrane current practice.
27
rupture may occur from 47 feet if there is no Pashley and Scholl showed, in vitro, that it took
equalization of pressure via the Eustachian tube.2 The 11.4522.57 cmH 2O to force water through a
common symptoms are hearing loss, otalgia, otorrhea, tympanostomy tube. While length and position of the
tinnitus and vertigo. The hearing loss is usually tube did not have any effect, soapy water or liquids
conductive, but sometimes sensorineural. The with decreased surface tension entered the tube more
treatments include topical or oral antibiotics and readily. The investigators described 3 necessary
analgesics. The perforations are, in most cases, small parameters for water to enter the middle ear: Eustachian
and will heal spontaneously in 1 month. If not, they tube opening, fixation of the tympanic membrane,
can be repaired by tympanoplasty. and increased external canal pressure.27 Hebert et al28
designed a model of the human ear with pinna,
Swimming, chronic otitis media and external ear canal, tympanic membrane with ventilation
mastoidectomy tube, middle ear cleft, and mastoid cavity, and subjected
Swimming is not advised for patients with chronic the model to various conditions. Showering, hair
otitis media with active drainage, but is allowed for rinsing and head submersion in clean tap water did not
patients with eardrum perforation without discharge if promote water entry into the middle ear. However,
ear protection (e.g. earplugs) is used. For patients who head submersion in soapy water and swimming deeper
have undergone mastoidectomy or tympanoplasty with than 60 cm produced a significant number of positive
mastoidectomy, swimming is allowed if there is no test results (water entry into the middle ear).28 Morgan29
23,24
discharge or cavity problem. The cavity should be used fluorescent powder to show the extent of water
lined with healthy epithelium, and ear protection is penetration into the external ear canal and tympanic
needed when swimming. If the patient has a discharging membrane. He showed that water on the tympanic
cavity or granulation tissue in the cavity, swimming membrane was found in 13.5% of cases of hair washing,
should be restricted. For patients with a large open and in 52% cases of head submersion in water for 4
cavity, swimming may cause vertigo because of caloric minutes.29
effects.23 However, patients who have undergone surgical Several prospective studies and meta-analyses
obliteration of the tympanomastoid compartment and showed no difference in the incidence of otorrhea
external auditory canal may participate in swimming, among swimmers and nonswimmers in a group of
diving, and all other aquatic sports.25 children with ventilation tubes.3038 All of these studies
and analyses concluded that swimming should not be
Children with ventilation tubes prohibited in children with ventilation tubes.3038
Can children with ventilation tubes be allowed to Generally, diving is not advised for children with
38
swim without protection? This common question ventilation tubes. Lounsbury studied the effects of
asked by parents in ear, nose and throat clinics is unprotected swimming in patients with ventilation
controversial and has been debated for decades. Some tubes. Divers had a significantly increased rate of
clinicians consider it safe for such children to swim infection versus nondivers (1 infection per 100 days of
without protection, whereas others consider it necessary swimming vs 1 infection per 600 days of swimming).38
for the children to swim with earplugs, and others Whether or not earplugs are used for swimming
stipulate that swimming should be strictly forbidden. seems to make no difference to the incidence of ear
Other contentious issues include the use of antibiotic infection in children with ventilation tubes. Becker et
ear drops after swimming, the feasibility of diving, and al31 reported an infection rate of 16% in individuals
the possibility of differences between locations, such swimming without earplugs, compared with 30% in
as chlorinated swimming pools, rivers, lakes, and individuals swimming with earplugs. Salata and
beaches. Derkay et al26 conducted a questionnaire Derkay34 also showed no difference in the rate of
survey of 1,266 otolaryngologists in the southern and otorrhea in children with tympanostomy tubes
eastern USA. Of all respondents, 14.1% prohibited swimming with or without earplugs.
swimming, 3.1% had no water precautions, and 68% Smelt and Monkhouse39 irrigated the middle ears
limited their patients swimming. The most frequently of guinea pigs with normal saline, bath water, sea
recommended protection was earplugs. Interestingly, water, and swimming pool water. They then sacrificed
94% of respondents said they would be willing to alter the animals and assessed histologic changes in the
their current practice based on new information middle ear mucosae. Reactive changes with swimming
generated from a clinical trial;26 this suggests that most pool water and seawater were no greater than with

350 J Chin Med Assoc August 2005 Vol 68 No 8

 Ear problems in swimmers

normal saline; however, a greater degree of benign tumors of the ear canal, and are usually noted
inflammation was noted in ears irrigated with bath in people swimming in cold water. The symptoms are
water, possibly because of easier contamination with accumulated debris, otorrhea, and conductive hearing
enteral bacteria.39 loss. The treatment for exostoses is transmeatal surgical
In our recent, unpublished, study, we included removal. Traumatic eardrum perforations may occur
9 children with ventilation tubes in a total of 15 ears. during water skiing or scuba diving. Previous recurrent
After surface swimming for 1 hour without any ear otitis media, atrophic scarring of the tympanic
protection in a clean chlorinated swimming pool, the membrane, and poor Eustachian tube function may be
children had their ears checked by videotelescope at predisposing factors. The common symptoms are
the poolside. Eight ears were dry, 4 had water in the hearing loss, otalgia, otorrhea, tinnitus and vertigo.
outer third of the external ear canal, and 3 had water Tympanoplasty may be needed if the perforations do
on the tube or tympanic membrane, but none had not heal spontaneously. Swimming is not advised for
water penetration into the middle ear. No otorrhea patients with chronic otitis media with active drainage,
was found, even after 2 weeks. Thus, water penetration but is allowed for patients without discharge or cavity
through ventilation tubes into the middle ear is unlikely problems after mastoidectomy with or without
to occur with surface swimming, so children with tympanoplasty.
ventilation tubes can enjoy swimming without In children with ventilation tubes, it is not easy for
protection in clean chlorinated swimming pools. water to penetrate into the middle ear during surface
swimming, so earplugs are not required; diving is not
recommended. If middle ear infection or otorrhea
Inner Ear occurs, it is not difficult to manage. It is safe for
children with ventilation tubes to enjoy surface
Inner ear injury on diving swimming in clean chlorinated swimming pools.
Sudden sensorineural hearing loss and some degree of Sudden sensorineural hearing loss and some degree of
vertigo may occur after diving because of rupture of vertigo may occur after diving because of labyrinthine
the round or oval window.40 Rupture of the round fistula due to rupture of the round or oval window
window may occur after diving, even if the dive is membrane.
performed from a low height and no contact is made
with the bottom of the pool. Besides direct contusion
to the external ear and barotrauma, other causes such References
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