Ear infection (otitis media)

Overview

Ear infections are common, especially in children, and usually settle without intervention. In the middle ear, blocked or swollen eustachian tubes let fluid build up behind the eardrum, which can lead to infection. Both viruses and bacteria can be responsible. Typical signs are earache, a fever, difficulty hearing and fluid leaking from the ear. Many ear infections get better on their own within about 3 days, and complications are rare.

Symptoms

What a clinician may find

• Redness of the eardrum, a bulging eardrum or fluid behind it on looking into the ear
• Discharge from the ear, which can come through a perforated eardrum
• Fluid in the middle ear detected by pneumatic otoscopy

Complications

• Slight short-term hearing loss during and just after the infection, because of fluid in the ear
• Glue ear, a build-up of fluid in the middle ear that can follow colds and infections
• A torn (perforated) eardrum, which is rare
• Spread of infection to the mastoid bone behind the ear (mastoiditis) or, rarely, to the meninges
• Chronic otitis media or an abscess, which are rare

Diagnosis

A clinician usually looks into the ear with an otoscope, checking for redness, a bulging eardrum or fluid behind it. Pneumatic otoscopy and tympanometry are used to confirm fluid in the middle ear. If a child's hearing is a worry, a GP can refer them to audiology for a hearing test.

Treatment

Many cases get better on their own, and for mild cases a clinician may recommend watchful waiting or delayed antibiotic prescribing. Paracetamol or ibuprofen can ease discomfort. Antibiotics are not usually offered for middle ear infections, because they make little difference to symptoms. NICE guideline NG91 describes no antibiotic or a back-up antibiotic prescription as the options for most children with acute otitis media, with some exceptions. A GP or pharmacist may prescribe eardrops or tablets for some types of ear infection.

Prevention

The CDC advises receiving recommended vaccines, such as the flu and pneumococcal vaccines, because pneumococcal vaccine protects against a common cause of middle ear infections. The CDC also advises not smoking and avoiding secondhand smoke. MedlinePlus lists hand washing, breastfeeding and avoiding pacifiers among ways to lower risk.

Key facts

What are the symptoms of an ear infection?

The main signs of an ear infection are earache, a fever, difficulty hearing and fluid leaking from the ear. The NHS describes ear infections as common, especially in children. Young children and babies may rub or pull at the ear, be irritable or restless, be off their food, not react to some sounds or keep losing their balance. MedlinePlus says infants may show mainly irritability or crying that is hard to soothe, while older children and adults more often report ear pain, a feeling of fullness and hearing loss in the affected ear.

The NHS says that ear infections often get better on their own within about 3 days, although symptoms can sometimes last up to a week. The CDC lists symptoms lasting more than 2 to 3 days, worsening symptoms, and pus or fluid draining from the ear as reasons to see a healthcare provider. Discharge from the ear can come through a perforated eardrum.

What causes ear infections?

Both viruses and bacteria can cause an ear infection. The CDC names Streptococcus pneumoniae and Haemophilus influenzae as the two most common bacteria involved, and says cold viruses can also cause middle ear infections. The eustachian tube normally drains fluid from the middle ear. When it becomes blocked, fluid can collect behind the eardrum and become infected. MedlinePlus lists allergies, colds and sinus infections, excess mucus and saliva during teething, infected or overgrown adenoids and tobacco smoke as contributing factors.

Several risk factors are described. A 2017 review found that day care attendance and a family history of ear infections remain major risk factors. MedlinePlus lists pacifier use among the risk factors, and one Australian study linked not being breastfed with ear infection. The CDC says children whose parents smoke around them get more ear infections. The CDC also says pneumococcal vaccine protects against a common cause of middle ear infections.

How is an ear infection diagnosed?

A clinician usually looks into the ear with an otoscope. They check for redness, a bulging eardrum or fluid behind the eardrum. Reviews list fever, discharge from the ear, a full or bulging cloudy eardrum, reduced movement of the eardrum and redness as signs of acute otitis media. Ear pain is one of the more reliable indicators, but many young children show only nonspecific signs.

Pneumatic otoscopy and tympanometry are used to confirm fluid in the middle ear. One review notes that a diagnosis of acute otitis media should not be made when these tests do not show fluid. Infection of the outer ear, known as swimmer's ear, is a separate condition from a middle ear infection. If a child's hearing is a worry, a GP can refer them to audiology for a hearing test.

How is an ear infection treated?

Many cases get better on their own, so a clinician may recommend watchful waiting. The CDC says a provider may suggest waiting 2 to 3 days before prescribing antibiotics for a mild infection. Paracetamol or ibuprofen can ease discomfort, and the NHS says children under 16 should not take aspirin. The NHS advises keeping cotton buds and fingers out of the ear, keeping water out of it and not swimming during an ear infection. Decongestants and antihistamines are not recommended, because there is no evidence that they help.

NICE says most ear infections clear up within 3 days, although symptoms can sometimes last up to a week. Antibiotics are not usually offered for middle ear infections, because they make little difference to symptoms. NICE guideline NG91 describes no antibiotic or a back-up antibiotic prescription as the options for most children. A back-up prescription can be used if symptoms significantly worsen or do not improve within 3 days. Immediate antibiotics are offered where a child is very unwell, has signs of a more serious illness or is at high risk of complications. NICE says antibiotics might also be given if fluid is coming out of the ear, or if a child under 2 has infection in both ears.

What complications can an ear infection cause?

Most children have slight short-term hearing loss during and just after an ear infection, because of fluid in the ear. MedlinePlus lists rarer complications as a torn eardrum, spread of infection to the mastoid bone behind the ear or to the meninges, chronic otitis media and abscess. Swelling and tenderness behind the ear are among the signs of mastoiditis described in reviews.

Glue ear is a build-up of fluid in the middle ear. The NHS says it often clears up on its own within 3 months. Hospital leaflets describe it as especially common in young children, most often between 2 and 5, with mild to moderate hearing loss that may affect one or both ears. One UK parent guide says glue ear needs treating only if it causes persistent hearing loss, speech delay or recurrent ear infections. Grommets are tiny tubes placed in the eardrum, and hearing aids are another option for persistent glue ear. The NHS says antibiotics are not a standard treatment for glue ear.

When should you get medical help?

The NHS advises asking for an urgent GP appointment or getting help from NHS 111 if a person with ear infection symptoms feels generally unwell, has a very high temperature, has swelling around the ear, has new hearing loss, has fluid coming out of the ear, or feels dizzy or is being sick. A child under 12 months with earache in both ears is also on that list.

The NHS advises seeing a GP if earache lasts more than 3 days or keeps coming back. One NHS trust page says to call 999 or go to an urgent and emergency care centre for extreme pain, or for pain, tenderness, swelling or redness over the bone behind the ear. MedlinePlus, a US source, lists swelling behind the ear, severe pain, a high fever, severe headache, dizziness and twitching of the facial muscles as reasons to contact a health care provider. In an emergency, call 999.

Frequently asked questions