Swimmer’s ear may sound simple, but the wrong drop can create real safety concerns.
In this episode, TRC Healthcare Assistant Editor and Clinical Pharmacist Gina Corley, PharmD, reviews practical swimmer’s ear treatment considerations for healthcare teams, including how eardrum and ear tube status affect which otic drops are appropriate. She also discusses swimmer’s ear prevention strategies, along with guidance on how to administer ear drops.
This is an excerpt from our June 2026 Pharmacy Essential Updates continuing education webinar series.
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Transcript:
This transcript is automatically generated.
00:00:05 Narrator
Could the wrong ear drop put a patient’s hearing at risk?
00:00:08 Narrator
What should you ask before recommending treatment for swimmer’s ear?
00:00:20 Narrator
On this episode, Assistant Editor and Clinical Pharmacist Gina Corley reviews practical swimmer’s ear treatment considerations for healthcare teams, including how ear tubes and eardrum status affect which otic drops are appropriate in an excerpt from our popular Pharmacy Essential Updates webinar series.
00:00:38 Narrator
This podcast offers Continuing Education credit for pharmacists and pharmacy technicians. Please log in to your Pharmacist’s Letter or Pharmacy Technician’s Letter account and look for the title of this podcast in the list of available CE courses.
00:00:50 Narrator
None of the speakers have anything to disclose.
00:00:53 Narrator
Catch new episodes of Clinical Capsules every 2nd and 4th Tuesday—bringing concise, actionable insights from TRC experts straight to your ears.
00:01:02 Narrator
With that, let’s get started.
00:01:10 Gina Corley
So today we’ll go through what swimmer’s ear is, what types of medications you can expect to see, certain caveats for prescribing these medications, and some practice pearls at the end.
00:01:24 Gina Corley
All right, let’s jump in.
00:01:28 Gina Corley
So swimmer’s ear is an infection in the outer ear canal, which is why we’ll sometimes hear this infection called acute otitis externa.
00:01:40 Gina Corley
The outer ear is the part that runs from the eardrum to the outside of the head.
00:01:46 Gina Corley
Swimmer’s ear tends to happen when excess water gets trapped in the ear canal, since the excess moisture creates an optimal environment for bacteria to grow.
00:02:00 Gina Corley
The two types of bacteria that most often cause swimmer’s ear are Pseudomonas aeruginosa and Staphylococcus aureus.
00:02:12 Gina Corley
So keep in mind that when we talk about treatments, the preferred meds are the ones that will cover against these bugs.
00:02:21 Gina Corley
And just as an FYI, sometimes swimmer’s ear can be a fungal infection instead of a bacterial infection, but this is less common.
00:02:34 Gina Corley
And then as far as symptoms, you’ll often hear patients that get swimmer’s ear complain of pain, itchiness, or a feeling of fullness in the ear due to all the water trapped inside.
00:02:49 Gina Corley
So when it comes to medications, topical antibiotic ear drops are typically first line.
00:02:56 Gina Corley
These work best because they deliver the medication directly to the site of infection.
00:03:04 Gina Corley
Some of these topical antibiotics come combined with a steroid, which may relieve pain a day sooner.
00:03:13 Gina Corley
We normally want to avoid systemic antibiotics in swimmer’s ear because they can produce more side effects and are typically much less effective than topicals.
00:03:27 Gina Corley
Exceptions to this would be if the infection spreads beyond the ear or if the patient has risk factors for necrotizing otitis, which is a severe and sometimes fatal infection that spreads from the outer ear canal into the skull bones.
00:03:46 Gina Corley
Patients at high risk for this typically include elderly patients with diabetes or those who are immunocompromised.
00:03:57 Gina Corley
Now, when it comes to treatment, we want to base our choice on eardrum status, cost, dosing frequency, and convenience, since one eardrop has not been shown to be better than another.
00:04:11 Gina Corley
But before we explore the individual meds, let’s take a closer look at what we mean by eardrum status.
00:04:19 Gina Corley
So one of the things that we want to ask when patients are getting ear drops is if they have a perforated or ruptured eardrum, or if they have ear tubes.
00:04:29 Gina Corley
And this is because we want to avoid ear drops that are non-sterile or ototoxic in these patients.
00:04:38 Gina Corley
Patients with a ruptured eardrum, also called a perforated tympanic membrane, essentially have a hole in their ear.
00:04:46 Gina Corley
So non-sterile or ototoxic medications can easily get down into the middle and inner part of the ear and cause things like permanent hearing loss, chronic middle ear irritation, and secondary infections.
00:05:01 Gina Corley
And of course, this is also a risk if someone has ear tubes, since these tubes are placed directly into the eardrum.
00:05:10 Gina Corley
So just as a quick summary, when we hear about an ear drop being ototoxic, this essentially means it’s toxic or harmful if it gets into the middle part of the ear.
00:05:24 Gina Corley
But it’s fine to put these drops along with non-sterile ear drops in the outer ear canal.
00:06:04 Gina Corley
So now let’s explore the various options.
00:06:08 Gina Corley
You’ll see that many of them involve a quinolone antibiotic, so like plain ciprofloxacin or ofloxacin.
00:06:17 Gina Corley
Or these can be combined with a steroid like I mentioned.
00:06:20 Gina Corley
So we have ciprofloxacin with dexamethasone or ciprofloxacin with hydrocortisone as a couple examples.
00:06:29 Gina Corley
But one important distinction that I want to point out here is that ciprofloxacin with dexamethasone is fine to use in patients with a perforated eardrum or ear tubes.
00:06:42 Gina Corley
But ciprofloxacin with hydrocortisone is not sterile and therefore should be avoided in these patients.
00:06:50 Gina Corley
Another antibiotic combo drop that we have is neomycin, polymyxin B, and hydrocortisone or Cortisporin.
But this one should also be avoided in patients with a perforated eardrum or ear tubes.
00:07:04 Gina Corley
And this is partially because neomycin, which is an aminoglycoside antibiotic, can cause hearing loss and also damage the hair cells of the inner ear.
00:07:17 Gina Corley
The other reason is because this combo has high acidity and can cause burning and stinging, which hurts much worse if it gets into the sensitive tissues of the inner ear.
00:07:29 Gina Corley
Another caveat with Cortisporin is that it comes as a suspension and a solution.
00:07:35 Gina Corley
And this suspension is often preferred due to it being less irritating.
00:07:41 Gina Corley
And then I also wanted to mention that acetic acid ear drops can be used since acetic acid has antimicrobial properties.
00:07:50 Gina Corley
But these drops are ototoxic and non-sterile, so we can’t give these to patients with a ruptured eardrum or ear tubes either.
00:08:00 Gina Corley
In terms of cost, ear drops with a steroid are sometimes a bit more costly than plain antibiotic ear drops.
00:08:08 Gina Corley
So if cost is a major concern, we can suggest ofloxacin 0.3% ear drops since these are under $30 per bottle.
00:08:17 Gina Corley
Or another option is to use eye drops in the ear.
00:08:22 Gina Corley
All right, so let’s talk a little more about using eye drops in the ear.
00:08:27 Gina Corley
Most eye drops can be used in the ear because they’re manufactured to be extremely sterile and have a more stable pH balance.
00:08:36 Gina Corley
And of course, this is because eye tissue is a lot more sensitive than ear tissue.
00:08:42 Gina Corley
But we always want to keep in mind that the reverse is not true, and ear drops should never be used in the eye.
00:08:50 Gina Corley
So it’s important to really pay attention when we get prescriptions for both eye and ear products.
00:08:58 Gina Corley
For one thing, these meds have similar packaging, and so it’s easy to grab the wrong one.
00:09:04 Gina Corley
But another big reason is that the same antibiotic can be manufactured as an eye drop and as an ear drop.
00:09:12 Gina Corley
So, for instance, ofloxacin comes as a 0.3% ophthalmic solution and a 0.3% otic solution.
00:09:23 Gina Corley
So why would we want to use eye meds in the ear?
00:09:27 Gina Corley
Well, like I said, a big reason is often cost, since eye drops sometimes tend to cost less than ear drops.
00:09:35 Gina Corley
For instance, ciprofloxacin 0.2% ear drops cost over $100 per box, whereas ciprofloxacin 0.3% eye drops cost less than $25 per bottle.
00:09:49 Gina Corley
So this is 1 scenario that if the prescriber wanted to use ciprofloxacin, that they could prescribe the eye drops instead of the ear drops.
00:09:59 Gina Corley
If patients also need something for pain, we can recommend adding oral acetaminophen or an NSAID such as ibuprofen.
00:10:08 Gina Corley
These are typically only used for the first 48 to 72 hours of the infection since patients should start to get relief from their topical treatment within this timeframe.
00:10:19 Gina Corley
Suggest scheduled doses of these analgesics since this may control severe pain better than using them as needed.
00:10:29 Gina Corley
However, we typically want to discourage ear drops for pain.
00:10:34 Gina Corley
OTCs, such as Ear Pain MD, that contain lidocaine may provide temporary pain relief, but they may also mask symptoms of a worsening infection.
00:10:46 Gina Corley
And then other drops, such as sweet oil or Hyland’s Earache Drops, aren’t likely to help.
00:10:53 Gina Corley
Plus, these drops should also be avoided in patients with ear tubes or a perforated eardrum because most are not sterile.
00:11:03 Gina Corley
And then real quick, I wanted to touch on a couple things we want to avoid when it comes to treating swimmer’s ear.
00:11:10 Gina Corley
First, we want to discourage home remedy treatments, such as isopropyl alcohol mixed with white vinegar, since these have no evidence of benefit.
00:11:21 Gina Corley
And then we also want to tell patients to avoid ear candles, because these can actually cause harm and lead to things like hearing loss and tympanic membrane perforation.
00:11:33 Gina Corley
So now that we know how to treat swimmer’s ear, let’s talk about how to prevent it.
00:11:40 Gina Corley
For starters, patients can use earplugs or ear protection headbands, such as Neoprene or Ear Band-It, while swimming to help keep water out of the ear.
00:11:50 Gina Corley
However, some data show that earplugs may irritate the ear canal.
00:11:55 Gina Corley
So if this happens, we can always suggest another option.
00:11:59 Gina Corley
Patients can also try OTC isopropyl alcohol drops such as SwimEar or Debrox after swimming to help dry out the ear canal.
00:12:09 Gina Corley
I know we just said not to use isopropyl alcohol mixtures for treatment, but it may help with prevention.
00:12:17 Gina Corley
Another option is to use a hair dryer on the lowest setting, several inches from the ear to dry the ears after water exposure.
00:12:26 Gina Corley
Patients can also apply acetic acid drops after the ears are dry, and these work by lowering the pH of the ear canal, which creates a more unfavorable environment for bacteria to thrive.
00:12:42 Gina Corley
All right, now let’s go over some practice pearls when it comes to swimmer’s ear.
00:12:47 Gina Corley
As we mentioned in the treatment section, many meds have similar ingredients or names.
So stay alert for mix-ups such as between Ciprodex, Cipro HC, and ciprofloxacin ear or eye drops.
00:13:02 Gina Corley
Next, we want to ensure we’re using the right drops per mL conversion factor when calculating days supply.
00:13:11 Gina Corley
Many pharmacies or payers use 20 drops per mL, but some use 15 to 16 drops per mL, depending on the med.
00:13:21 Gina Corley
And using the wrong one could lead to chargebacks.
00:13:25 Gina Corley
We also want to include a “For the ear” label on drops for swimmer’s ear, especially when eye drops are being used in the ear.
00:13:35 Gina Corley
And then we want to let patients know that swimming should be avoided during treatment, so the infection does not get worse.
00:13:43 Gina Corley
But competitive swimmers can sometimes return to the pool sooner, around two to three days after pain has resolved.
00:13:50 Gina Corley
They’ll just want to make sure that they use well-fitting earplugs.
00:13:55 Gina Corley
All right, so lastly, let’s go over how to properly administer ear drops.
00:14:01 Gina Corley
We want to start by telling patients to warm the bottle in their hands, which can help offset any discomfort if the drops happen to be a little cool.
00:14:11 Gina Corley
Next, we want to have patients lie down with their affected ear facing up.
00:14:16 Gina Corley
For adults, we can tell them to pull the upper part of the ear up and back, and for kids, we can suggest pulling the lower part of the ear down and back.
00:14:26 Gina Corley
This helps to straighten out the ear canal.
00:14:31 Gina Corley
After that, patients will apply the correct number of drops into the ear and massage the tragus area, which is the small flap of cartilage sticking up right next to the face.
00:14:43 Gina Corley
This can help the ear drops really soak into the ear.
00:14:47 Gina Corley
Ideally, patients will want to stay with their head in this position for about 5 minutes, and then the ear can drain and dry naturally.
00:14:58 Narrator
Thanks for listening—we hope today’s episode gave you practical insights you can use right away.
00:15:03 Narrator
Now that you’ve listened, pharmacists and pharmacy technicians can receive CE credit. Just log into your Pharmacist’s Letter or Pharmacy Technician’s Letter account and look for the title of this podcast in the list of available CE courses.
00:15:15 Narrator
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00:15:27 Narrator
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00:15:44 Narrator
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00:15:58 Narrator
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00:16:13 Narrator
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00:16:28 Narrator
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