When your child says, “My ear hurts,” you might wonder, “Does he have an ear infection?”

What many parents don’t know to ask is, “Which type of ear infection could it be?”

There are, in fact, two common types of ear infections in children. Middle ear infection, or “otitis media,” is an infection behind the eardrum that’s most common in infants and toddlers. Outer ear infection, or “otitis externa,” is an infection of the ear canal that’s more common in older children. It’s also known as “swimmer’s ear” since it often develops in children and adults who swim frequently.

This article will review what parents need to know about outer ear infections.

What are outer ear infections and what causes them?

Outer ear infections are infections of the external ear canal that extend from the outer ear flap to the eardrum. They’re caused by water trapped in the ear canal, usually from swimming or showering, which creates a warm, moist environment for bacteria and fungus. They’re more common after swimming in contaminated water and in hot, humid climates. Infections are also more likely if the ear canal has been scratched (from picking inside the ear with a finger, a cotton swab or a sharp object) or the skin has cracks or breaks from a condition such as seborrhea or psoriasis. They’re more common in people with medical conditions that reduce the body’s immunity, such as diabetes or HIV/AIDS.

Contrary to what many people believe, earwax usually protects the ear canal from moisture and infection. That’s why parents should not try to remove earwax from children’s ear canals. Rarely, some people produce too much earwax, which can block the ear canal and trap moisture, leading to outer ear infections. If you think your child has this problem, ask the doctor to remove the wax.

What are the symptoms of outer ear infections?

Outer ear infections cause ear pain, which tends to increase when touching the ear, lying down on it or chewing food. If your child complains of ear pain, gently grab the outer ear and wiggle it. If the discomfort increases, an outer ear infection is likely.

Outer ear infection can also cause itchiness in the ear, a feeling that the ear is plugged up or hearing problems. You may notice pus or bloody fluid draining from the ear or on your child’s shirt or pillow. Fever is rarely involved.

How are outer ear infections diagnosed?

If you think your child might have an outer ear infection, take him to the doctor. The doctor will examine his head and neck, gently wiggle his outer ear and look in the ear with an otoscope. Depending on how much swelling and pus is in the ear canal, the doctor may try to clean it out to help get the ear drop treatment into the canal and check for a ruptured ear drum or middle ear infection, which might require a different treatment.

How are outer ear infections treated?

• Eardrops. Unlike middle ear infections, which are often treated with oral antibiotics, outer ear infections are usually treated with eardrops. The standard eardrops contain a mixture of antibiotics and may also contain a steroid, which can reduce the inflammation and slightly speed recovery. If your child has ear tubes (tympanostomy) or a perforated eardrum, a special antibiotic may be prescribed. Depending on which eardrop is prescribed, it may require several drops two to four times a day for seven to 10 days. To put in the drops, warm the bottle in your hands. Lay your child on her side with the infected ear facing up. Drop several drops directly into the canal, not onto to the outer ear. Move the earlobe back and forth to help the medicine drip down into the ear canal. If your child won’t lie still afterward, you can insert a small cotton ball to help keep the drops in the ear.
• If the ear canal is very swollen, the doctor might insert gauze or a foam wick to help get the drops in. When a wick is required, it’s usually recommended that you apply the drops to the outer part of the wick every three to four hours while your child is awake and return to the doctor in two to three days to check the ear and remove the wick if it’s no longer needed.
• If there is a sign of a more serious infection, oral antibiotics may be prescribed. Oral antibiotics may be given if: there are signs of extension of the infection to skin and tissue around ear; your child has a temperature above 101 F (38.3 C), which may be a sign of a middle ear infection; she has a medical condition impairing her immunity (e.g., diabetes, immune deficiency) or you’re unable to give the drops.
• Pain medication. If your child experiences a lot of ear pain, you can give him acetaminophen or ibuprofen as recommended by your doctor. The pain should subside within a few days.
• Ear candles are not recommended. They have not been shown to work and can cause burns and perforated eardrum.
• If your child isn’t getting better within 48 to 72 hours, call the doctor. It’s important to keep your child’s ear as dry as possible for seven to 10 days. Have her take baths instead of showers and don’t let her swim. Protect her ear during bathing and hair washing by inserting a cotton ball lightly coated with petroleum jelly in the ear canal.

How can we prevent outer ear infections?

• Don’t remove earwax from your child’s ears. If you think he has too much, see the doctor.
• Tell your child not to insert his fingers, cotton swabs or any other object in his ears. Follow the adage: “Don’t put anything in your ear that’s smaller than your elbow.”
• Don’t let your child swim in contaminated water. If there are signs for pollution alerts, don’t go in.
• When swimming, use a tightly fitting swim cap if possible. Avoid earplugs, which can scrape the ear canal and lead to infection.
• After swimming, make sure your child dries out his ears. Use the tip of a towel or a tissue. Tip the head to the side while pulling the ear lobe and having your child bounce up and down to shake out the water. You can also use a hair dryer on the lowest setting, held several inches from the ear.
• Ask your doctor about eardrops to prevent infections. If it’s difficult to get water out of your child’s ears after swimming, you can dry out the ear canal with a few drops of alcohol-based drops, available at your pharmacy. If your child has repeated outer ear infections, the doctor might recommend using eardrops with a solution of 2 percent acetic acid to restore the protective acidity in the ear canal and prevent infection.

For information about middle ear infections, refer to two articles on this website: “Ear Infections: What Parents Need to Know” and “Treating Ear Infections: The New 2004 Recommendations.”