For straightforward cases of AOE that do not involve cellulitis, necrotizing otitis externa, or other complicating factors (e.g., diabetes or immuno­­suppression), there does not appear to be any advantage to administering systemic antimicrobials.1,18 Addition of oral antibiotics will not improve symptoms, compared with using topical agents alone.^1,18

Instruct patients to use the drops for at least a week, continuing use for a few days after symptoms resolve. Most patients have resolution of symptoms by 6 days after starting treatment.16 If no improvement is noted in 48-72 hours, or if symptoms persist beyond 2 weeks, consider switching to a different agent.^1,16

Patients with AOE should avoid submerging their heads in water for 7-10 days, but competitive swimmers might be able to return to the pool if pain has resolved and they use well-fitting ear plugs.¹

Although AOE readily responds to appropriate treatment, it is a disease that can be prevented by some simple measures. So what do you tell families about preventing AOE? Addressing the subject at the first encounter might head off more visits later in the summer swim season and help ensure that kids won’t have to miss out on all the summer fun. The literature is sadly lacking in scientific studies on preventive measures, so we rely instead on reducing established predisposing factors.^1,16,18

Strategies for preventing AOE involve limiting water content in the ear canal and maintaining a barrier of healthy skin (see sidebar, p. 26). Keeping ears as dry as possible is important in both treating and preventing AOE. Tell your patients to dry their ears thoroughly after swimming or bathing. Use a towel to dry the ear, tilt the head to each side in turn to allow water to drain from the down-turned ear, and consider using a blow dryer set on the lowest heat and fan speed held several inches away from the ear.^{6,8,9,16,19-21}

Some sources recommend using alcohol-based ear drops after swimming (or each morning and evening) to reduce moisture content in the ear canal, correct the ear pH, and reduce bacterial growth.^9,16,19-24 Commercially prepared, alcohol-based ear-drying solutions are available, or patients can make their own 1:1 mixture of rubbing alcohol and white vinegar. Note that these drops should not be used in the presence of ear tubes, perforated tympanic membranes, or acute external ear infection.

Instruct patients and parents to avoid putting objects into the ear canal, even if the ear feels moist, itchy, or blocked with cerumen. Nothing should be put into the ears, including fingers or cotton-tip swabs.^7-10,19-21