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Medical mystery: Did the hot tub cause his earache?

The middle-aged patient's self-diagnosis made sense. Until it didn't.

Relaxing, sure, but what if the water gets in his ears?
Relaxing, sure, but what if the water gets in his ears?Read moreandresr / Getty Images

A middle-aged man went to his local urgent care clinic, certain that he had an ear infection.

His self-diagnosis made sense. He had been spending more time than usual in a hot tub, occasionally submerged enough to get water in his right ear. The “swishing” sensation of water persisted for two days until his ear began to hurt. He figured it was swimmer’s ear, an infection in the outer ear, caused by bacteria that grow in a moist environment. The examining physician agreed, and the patient left for home with some ear drops, and instructions to avoid swimming or hot tubs for a week or so.

A few days later, things were no better, and this frustrated gentleman came to our office to see one of my colleagues. Once again, the examination suggested an external ear infection, apparently unfazed by the drops, so this time oral antibiotics were suggested. The oral medicine was stronger, and more likely to get in and kill the responsible bacteria.

But my colleague was a bit unsettled. She knew it was unusual for an otherwise healthy man to have such a stubborn ear infection. Along with the antibiotic, she prescribed a warning and a backup plan: “If you are not improving in a day or two, or you notice swelling or a skin rash, please call or come back in right away.” Two days after seeing my colleague, a few raised bumps appeared in the patient’s outer ear canal, just barely visible in the mirror.

And by now, the pain of his “swimmer’s ear” was excruciating.

What was really going on?


It turned out that the man didn’t need to come back to our office. It so happened that our patient had a routine dermatology appointment the day he saw the ear rash, and the diagnosis was made on sight: shingles.

Shingles is a painful, blistering skin rash caused by re-activation of the varicella, or “chickenpox,” virus. It can occur in anyone who has had chickenpox and can show up just about anywhere on the body. It often masquerades as other conditions because the pain may start before the rash appears.

» READ MORE: Have Medicare? The shingles vaccine will cost you.

Treatment includes antivirals, pain relievers and sometimes a steroid such as prednisone. The best treatment, though, is prevention. A highly effective and safe shingles vaccine is available for adults aged 50 and over, available at most pharmacies and primary care doctors’ offices. Avoiding shingles is important both because it’s a miserable experience and also because in a minority of cases, people who have had shingles may develop a truly terrible complication called post-herpetic neuralgia, which can mean unremitting and severe pain.

As the saying goes, common things — such as swimmer’s ear — are common. But when the circumstances are unusual or the symptoms persists, we have to consider a less common problem in disguise.

Jeffrey Millstein is a primary-care physician and medical director for patient experience-regional practices of Penn Medicine.