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Ear Infections and Scuba Diving

Ear Canal Anatomy

Anatony of the external Ear Canal

Swimmer's Ear or Otitis Externa is an inflammatory and/or infectious process of the external ear canal, usually by bacteria, or less frequently, fungus. Otitis Externa can become extremely painful.

Initial presenting symptoms are usually pain in one ear only (but can be both), occasionally preceded by a mild itching sensation in the affected ear. The ear pain is usually sharp and may be significantly exacerbated by manipulating the outer ear. As the infectious process advances, the pain intensifies and the skin lining the ear canal can become so swollen as to effectively block the canal.

Diminished hearing may be present in the affected ear, usually caused by either impacted cerumen (ear wax) or swollen skin tissue with discharge (Otorrhea) blocking the canal, or discharge limiting the mobility of the tympanic membrane (ear drum).

Otitis Externa - Contributing Factors

The unique structure of the external ear canal contributes to the development of external ear infections (otitis externa) or commonly - swimmers ear. The ear canal is the only skin-lined cul-de-sac in the human body.

The external canal is warm, dark and prone to becoming moist, making it an excellent environment for bacterial and fungal growth. The skin lining the canal is very thin and easily traumatized. The exit of debris, secretions and foreign bodies is impeded by a curve the canal at the junction of the cartilage and bone and a "dip" just before the tympanic membrane.

The presence excessive ear wax (cerumen), which is created from a combination of the natural secretions from the canal sebaceous glands and constant microscopic shedding of epidermis (the skins outer layer), can be a further obstacle to the natural egress of fluids. Some individuals occasionally shed the epidermis in "sheets" - like skin "peeling" after sunburn, rather than small particles - like dandruff. These "sheets" can further obstruct the ear canal.

Fortunately, the external ear canal has some special defenses. Cerumen (ear wax) creates an acidic coating containing lysozymes and other substances that probably inhibit bacterial and fungal growth. The lipid-rich cerumen is also hydrophobic (repels water) and prevents water from penetrating to the skin and causing maceration. Too little cerumen can predispose the ear canal to infection, but cerumen that is excessive or too viscous can lead to obstruction, retention of water and debris, and infection.

Additionally, the canal is defended by a unique epithelial migration that occurs from the tympanic membrane outward, carrying any debris with it. When these defenses fail or when the epithelium of the external auditory canal is damaged, otitis externa results.

There are many factors contributing to external ear infections, but the most common is excessive moisture that elevates the pH and removes the cerumen, which is why Otitis Externa is commonly known as "Swimmer's Ear" and is a particular hazard to frequent swimmers, surfers, and scuba divers. Once the protective cerumen is removed, keratin debris absorbs the water, which creates a nourishing medium for bacterial growth.

Doctor John's Ear Drops are manufactured here in Utila and have been specially formulated to prevent ear infections by maintaining the natural environment of the external ear canal. The Acetic Acid ingredient has antibacterial and antifungal activity. The Aluminum Acetate ingredient helps to reduce itching, stinging, and inflammation that may be associated with an infection. The Propylene Glycol ingredient is hydrophilic and provides a low surface tension absorbing excess water in the ear and enabling the Ear Drop solution to better adhere to the epidermal surface of the ear canal.

This formulation is similar to the original Star Otic™, which has since been changed to contain mostly Isopropyl alcohol (95%), and Vosol™, both of which are indicated for the treatment of Otitis Externa.

Treatment of Otitis Externa

The affected ear canal needs to be inspected and the tympanic membrane visualized to rule out perforation. On inspection a judgment on the likelihood of bacterial versus fungal infection can be attempted, together with an assessment of the degree of swelling. If the tympanic membrane is intact, flushing the ear with purified water warmed to body temperature helps remove any existing debris.

A thorough examination of the head and neck should be performed to rule out other diagnoses and to look for possible complications of otitis externa. The examination should include evaluation of the sinuses, nose, mastoids, temporomandibular joints, mouth, pharynx and neck. In addition, if the tympanic membrane can be visualized and is red, appropriate measures should be used to ascertain whether associated otitis media is present.

If the ear canal is very swollen, an otic wick or otic tampon specially designed for this purpose may be inserted into the canal to facilitate drainage and permit application of topical medications.

Topical medications (ear drops) are the first line of treatment (antibiotic and/or antifungal), with oral antibiotics and even intramuscular antibiotics being reserved for the more severe cases. Treatment is typically for 5 to 7 days, but more severe cases may require 10 -14 days. Analgesics may be prescribed for siginifcant pain.

During treatment the affected ear should be kept dry at all times until the ear infection has resolved.

Prevention of Otitis Externa

Prevention of otitis externa primarily consists of avoiding the many contributing factors outlined above and treating any underlying chronic dermatologic disorders. This is particularly important for patients with unusually viscous cerumen, a narrowed external auditory canal or systemic allergies, especially in those who are immunosuppressed. Prevention is also important in patients who perspire excessively or participate in water sports regularly.

Doctor John's Ear Drops should be applied (3 drops to one ear, wait 5 minutes and apply 3 drops to other ear) before and after water sports. After immersion in water the external ear canal should be dried, possibly by using a hair dryer on the lowest heat setting, before applying the drops.

Some authorities recommend combining an acidifying agent, such as the Acetic Acid in Dr John's Ear Drops, with alcohol drops (such as Swim Ear) to act as an astringent, but many physicians feel this is too irritating and prefer using Burow's solution (Aluminum Acetate) as the astringent. Doctor John's Ear Drops contain both Acetic Acid and Aluminum Acetate.

Obviously, any manipulation of the skin of the external auditory canal (such as scratching or overzealous cleaning) should be avoided. Any time the external auditory canal is cleaned and cerumen is removed, the canal becomes more vulnerable to infection.

People who participate in water sports frequently may use a barrier to protect their ears from water, such as ear plugs. However, impermeable ear plugs can act as a local irritant and have been shown to predispose the ear canal to ear infections.


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