SB Medco-Acumed: Technical Reprints-Swimmer's Ear

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	Swimmer's Ear Acute and chronic otitis externa... an ear problem so common among swimmers that it is called "swimmer's ear." The author discusses the problems and their remedies. by John W. House, M.D. While serving as the team physician for the U.S. national swim team at the U.S. Open in Indianapolis, it was striking how many of the medical problems which I encountered were ear infections. Because of this common condition I felt that a review article into these problems is in order. Most of them are preventable. In order to understand the nature of ear infections, a review of the normal structures of the ear is helpful. The ear is divided into three parts: the external ear consisting of the pinna (cartilage and skin) and the ear canal. At the end of this canal is the tympanic membrane (ear drum). Beyond the ear drum is the middle ear. This part of the ear is separated from the outside by the normally intact tympanic membrane and contains the three bones of hearing. The malleus (hammer), incus (anvil) and stapes (stirrup) are the smallest bones in the body. In order to equalize pressure between the outside and the air containing middle ear space, we have a tube (eustachian tube) connecting the middle ear with the back of the nose. Sound entering the external ear travels as mechanical vibrations through the ear drum and the ear bones to the inner ear. This structure is divided into two parts, one for balance and the other for hearing. The cochlea, which resembles a snail shell, is the hearing part of the inner ear. It has 2 1/2 turns. It contains fluid which is set in motion by the vibration of the ear bones. Thirty thousand nerve endings (hair cells) sense this motion and convert this energy into electric impulses of one millionth of a volt. The nerve impulse is then sent to the brain where it is interpreted as sound. The other part of the inner ear is the vestibular semi-circular canals which help us to maintain our balance. The fluid within these canals flows back and forth to stimulate the vestibular nerve endings. These impulses are sent to the brain for interpretation. Our balance is maintained by an integration of this input plus information coming from our eyes and our joints and muscles (proprioception). Problems The single most common problem swimmers have with their ear is acute and chronic otitis externa. This condition is so common in swimmers that its common name is "swimmer's ear." It is caused most commonly by a bacteria called Pseudomonas aeruginosa, a common organism on the skin. This bacteria takes advantage of the chronic wet ear which has a lowered resistance to infection. Any scratch or irritation will allow this organism to cause an infection. Other causative organisms include Proteus, staphylococcus, streptococcal species and at times various fungi. The acute infection is characterized by severe, deep ear pain. The pain is usually either accompanied or preceded by itching. The external ear is tender to palpation and manipulation. The ear canal becomes red and swollen. There is rarely discharge or hearing loss associated with acute otitis externa. Treatment is by topical antibiotic drops instilled in the ear canal frequently. During the acute phase of the process, the ear must be kept dry. In these cases, tight-fitting ear plugs will not be tolerated because of the swelling. It is important for these swimmers to continue to train, so I recommend a soft ear plug such as the silicon ("ear putty") plugs by Physicians' Choice.™ (Santa Barbara Medco, Inc., makers of these ear plugs, is a sponsor of the United States Swimming Sports Medicine Program and the official supplier of ear plugs to the U.S. national swimming team.) These are also good to use during training as a way of preventing recurring infections. Using an acidic solution in the ear after exposure to water is helpful in preventing infections in those swimmers who tend to get swimmer's ear, This can be something as simple as white vinegar diluted half by either water or alcohol. Cotton swabs are never to be used to dry or clean the ear, They tend to remove wax which helps prevent infections and can scratch or irritate the ear. When the infection becomes chronic, the swimmer will experience recurrent acute episodes, constant itching and possibly scaling of the skin. This condition is treated by the use of ear plugs, such as Physicians' Choice, to keep water out of the ear, and topical steroid ear drops, In order to keep an acute episode of swimmer's ear from becoming chronic, the treatment has to be continued until well after the symptoms have subsided, This is usually several weeks. In younger swimmers, middle ear infections may be a problem. These can be either acute or chronic. Acute otitis media starts suddenly and is associated with a fever, pain and hearing loss. It is the result of a bacterial infection of the middle ear. The common causes are Streptococcus pneumoniae, Hemophilus influenzae and Bramhamella catarrhalis. On occasions, the ear drum may rupture and the ear will drain pus. The treatment is appropriate antibiotics and at times decongestants. The swimmer should not train or compete during the early stages of acute otitis media, but may return to the water after being on treatment for a few days and when the acute symptoms have subsided. During this time, water must be kept out of the ear with the use of ear plugs. If the tympanic membrane ruptures, water is kept from the ear until the drum has healed. If healing does not occur, the swimmer can continue to train and compete with the use of ear plugs. In cases where persistent perforations exist, surgery can be performed in order to repair the tympanic membrane. Young children are prone to eustachian tube problems and may develop persistent fluid in the middle ear (chronic serious otitis media). At times, an opening in the tympanic membrane is made (myringotomy), the fluid removed and tubes inserted in order to ventilate the middle ear. While these tubes are in place, the competitor must use ear plugs and even a bathing cap to keep the ears dry. Should water enter the ear, it may cause an infection by entering the middle ear through the open tube. On rare occasions, middle ear disease can become chronic and may lead to hearing loss, a permanent perforation with destruction of the ear bones or a cholesteatoma. This later condition requires surgery as soon as it is detected. In young adults who have been swimming for years, bony growths called exostosis may occur in the ear canal. These are not serious, but may eventually grow to a size that block the ear canal. Surgery is required to remove these growths and once again open the canal. Summary Because the swimmer spends many hours per day in the water, the ear is prone to certain types of infections. The most common of these is an infection of the ear canal (otitis externa). Fortunately this is not serious and may be prevented by the use of ear plugs and/or the use of ear drops after exposure. Middle ear infections occur in younger swimmers, as in any child, and are not a contraindication to swimming. During the acute stage, the swimmer should remain out of the water, but may return as soon as symptoms subside with the use of an ear plug. More serious problems are rare and do not preclude the active participation in water sports. Disclaimer This article contains information about swimmer's ear. Persons suffering from the conditions described herein should seek the advice of their physician. About the Author: John W. House, M.D., is president of the House Ear Institute in Los Angeles, Calif. He is a former AIIAmerican and nationally ranked swimmer.