Otitis externa — inflammation of the external ear canal — is one of the most common ear complaints pharmacists manage. Often called swimmer's ear because of its association with water exposure, the condition affects an estimated 1 in 10 people at some point in their lives, according to NHS data. Presentations increase markedly during summer months as swimming, water sports and holiday travel peak.

What Causes Otitis Externa?

The external ear canal is lined with skin that produces cerumen (earwax), which maintains a slightly acidic pH and creates a protective barrier against infection. Otitis externa develops when this barrier is disrupted.

Common triggers include:

The resulting inflammation creates a warm, moist environment ideal for bacterial or fungal overgrowth. Pseudomonas aeruginosa and Staphylococcus aureus are the most common bacterial causes; Aspergillus and Candida species account for fungal cases.

Symptoms to Recognise

Patients typically present with:

• Ear pain (otalgia), often severe and worsened by pulling the earlobe or pressing on the tragus
• Itching inside the ear canal
• A feeling of fullness or blockage
• Discharge — initially clear and watery, becoming thicker if infection progresses
• Reduced hearing if the canal swells significantly
• Redness and swelling visible at the canal entrance

The tragus tenderness test is a useful pharmacy screening tool: pain on gentle pressure to the small flap of cartilage in front of the ear canal strongly suggests otitis externa rather than middle ear infection (otitis media).

OTC Treatment Options

Acetic acid ear drops (EarCalm)

Acetic acid 2% spray (EarCalm) is the primary OTC treatment for mild otitis externa. It works by restoring the ear canal's natural acidic pH, creating an environment hostile to bacterial and fungal growth. One spray into the affected ear three times daily for seven days is the standard regimen.

It is suitable for adults and children over 12 years. Patients should be warned that it may cause a brief stinging sensation on application, particularly if the canal skin is inflamed.

Pain relief

Ear pain from otitis externa can be disproportionately severe. Pharmacists should ensure adequate analgesia:

• Ibuprofen 400mg three times daily (anti-inflammatory plus analgesic)
• Paracetamol 1g up to four times daily if NSAIDs are contraindicated
• Both can be combined for severe pain
• A warm (not hot) compress held against the ear provides additional comfort

What NOT to recommend

• Olive oil or sodium bicarbonate ear drops — these are for cerumen softening and may worsen otitis externa by further raising canal pH
• Cotton buds or ear candles — these are harmful in all ear conditions
• Swimming — advise patients to keep the affected ear dry until symptoms have resolved completely

Prevention Advice

For patients prone to recurrent otitis externa, pharmacists can offer practical prevention strategies:

• Use custom-moulded or silicone earplugs when swimming
• Tilt the head to drain water from ears after swimming or showering
• Dry the outer ear gently with a towel — never insert anything into the canal
• Avoid using cotton buds (the single most common preventable cause)
• Consider acetic acid drops prophylactically before and after swimming if episodes are frequent
• Remove hearing aids overnight to allow the canal to air

When to Refer

Pharmacy management is appropriate for mild, uncomplicated otitis externa in otherwise healthy adults. Referral to a GP is indicated if:

• Symptoms have not improved after seven days of OTC treatment
• There is significant canal swelling that prevents ear drop penetration
• The patient has a fever or spreading facial cellulitis
• Discharge is profuse, persistent or blood-stained
• The patient has diabetes or is immunocompromised (risk of malignant otitis externa, a serious complication)
• There is a history of ear surgery or tympanic membrane perforation
• The patient is a child under 12 years
• Hearing loss is significant or sudden

Malignant (necrotising) otitis externa is a rare but serious complication seen predominantly in elderly diabetic or immunocompromised patients. It involves infection spreading to the temporal bone and requires urgent secondary care referral.

Seasonal Preparedness

Otitis externa follows a predictable seasonal pattern, with presentations peaking between June and September. Pharmacies can prepare by ensuring adequate stock of acetic acid spray and positioning ear care products prominently during summer months. Proactive conversations at the counter — particularly with parents buying swimming equipment — can help patients prevent the condition before it develops.

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