Ear Infection: Outer, Middle and Inner Ear Infections Explained

Types of ear infection

Middle ear infection (otitis media)

The middle ear connects to the back of the nose through the eustachian tube. During a cold or allergy flare the tube swells shut. Fluid builds up behind the eardrum, and viruses or bacteria (often Streptococcus pneumoniae, Haemophilus influenzae or Moraxella) multiply in it. Pressure on the eardrum causes pain.

Children are more prone because their eustachian tubes are shorter, more horizontal and more easily blocked by adenoids. By age 3, most children have had at least one. For details on diagnosis and ear tubes, see otitis media and acute otitis media.

Fluid often stays after the infection has gone, causing muffled hearing for weeks. This is otitis media with effusion ("glue ear") and is not an active infection.

Outer ear infection (swimmer's ear)

Water left in the ear canal softens the skin and washes away protective wax, letting bacteria (often Pseudomonas or Staphylococcus) take hold. Scratching, cotton swabs, hearing aids and earbuds damage the skin in the same way. Swimmer's ear causes pain when you pull the earlobe or press the flap in front of the ear, itch, a swollen canal and discharge. Fungal outer ear infections cause more itch and a fluffy white or black discharge.

Inner ear infection

Inflammation of the inner ear, usually from a virus, causes sudden vertigo (the room spinning), nausea and unsteadiness. When hearing is also affected, it is called labyrinthitis. There is usually no ear pain. Sudden hearing loss needs a doctor within days, because early steroid treatment may improve recovery.

Ear infection symptoms in babies and toddlers

Babies cannot say their ear hurts. Signs include:

• Tugging or pulling at the ear, especially with other signs below
• Crying more than usual, especially when lying down
• Waking at night, poor sleep
• Fever
• Refusing feeds, because sucking and swallowing change ear pressure
• Fluid draining from the ear (the eardrum may have burst, which relieves pain)
• Not responding to quiet sounds, or clumsiness

Ear tugging on its own, in a baby who is otherwise happy and has no fever, is usually a habit or a sign of teething, not infection.

Ear infections in adults

Adults get fewer middle ear infections, but they do occur after colds, flights or with allergies. Adults are more likely to have swimmer's ear. Recurring middle ear infections in an adult, or fluid behind one eardrum that does not clear, should be checked by an ENT doctor to rule out a blockage at the back of the nose.

How an ear infection is diagnosed

A doctor looks at the eardrum with an otoscope. In a middle ear infection the eardrum is red, cloudy and bulging, and it does not move normally when a puff of air is applied. In swimmer's ear the canal is red and swollen and pulling the ear hurts. Swabs of discharge are taken when an infection keeps coming back or does not respond to treatment. Hearing tests are done if fluid persists.

Treatment

Middle ear infections

• Pain relief first: acetaminophen (paracetamol) or ibuprofen, at the label dose for age or weight. Do not give aspirin to children or teenagers.
• Watchful waiting: for children over 2 (and some over 6 months) with mild symptoms, doctors often wait 48 to 72 hours, because most infections clear on their own.
• Antibiotics: usually given to babies under 6 months, children under 2 with infections in both ears, anyone with ear discharge, severe pain or a fever of 39 °C (102.2 °F) or higher, and those who do not improve. Amoxicillin is the usual first choice.
• Ear tubes (tympanostomy tubes): considered for frequent infections or long-lasting fluid with hearing loss.

Outer ear infections

• Antibiotic or antibiotic-steroid ear drops for 7 to 10 days. Oral antibiotics are rarely needed.
• Keep the ear dry: cover it with cotton wool coated in petroleum jelly when showering, and avoid swimming until it heals.
• If the canal is too swollen for drops, a doctor can place a small sponge wick.

Home care

A warm or cold cloth held over the ear can ease pain. Do not put oils, garlic, hydrogen peroxide or cotton swabs into an ear that is infected or may have a burst eardrum.

Complications

Most ear infections heal without problems. Rarely:

• Burst eardrum: usually heals within a few weeks.
• Mastoiditis: infection spreads into the bone behind the ear, causing swelling and redness there.
• Hearing loss and speech delay from long-lasting fluid.
• Meningitis or brain abscess, which are rare but serious.
• Malignant otitis externa: a spreading bone infection of the ear canal in older people with diabetes.

Preventing ear infections

• Keep children away from cigarette smoke.
• Keep vaccines up to date, including pneumococcal and yearly flu vaccines.
• Breastfeed if possible for the first 6 months, and avoid bottle feeding while lying flat.
• Limit pacifier use after 6 months.
• Dry ears after swimming by tilting the head; use swimmer's earplugs if you get swimmer's ear often.
• Do not use cotton swabs inside the ear canal.

Frequently asked questions

Is tugging at the ears a sign of an ear infection?

It can be, especially with fever, crying when lying down, poor sleep or refusing feeds. On its own, in a happy baby without fever, ear tugging is usually a habit, self-soothing or linked to teething. A doctor can check the eardrum to be sure.

How do I know if my ear infection is outer or middle ear?

Pain when you pull the earlobe or press the flap in front of the ear, plus itch and a swollen, wet canal, suggests an outer ear infection. Deep pain, muffled hearing and fever after a cold suggest a middle ear infection. A doctor can confirm by looking with an otoscope.

Do ear infections go away on their own?

Many middle ear infections do, usually within 2 to 3 days, which is why doctors often recommend pain relief and waiting first in older children. Outer ear infections usually need medicated ear drops. Get checked if symptoms are severe or not improving after 2 to 3 days.

Are ear infections contagious?

The ear infection itself is not contagious. The cold or flu virus that led to it can spread to others, though, so handwashing and covering coughs still matter. Swimmer's ear is not contagious.

Can adults get ear infections?

Yes. Adults are more likely to get outer ear infections (swimmer's ear) than children, and can get middle ear infections after colds, flights or allergies. Repeated or one-sided middle ear fluid in an adult should be checked by an ear, nose and throat specialist.

When should I see a doctor for an ear infection?

See a doctor for a baby under 6 months with ear symptoms, fever of 39 °C (102.2 °F) or higher, severe pain, discharge from the ear, swelling behind the ear, dizziness, or symptoms not improving after 2 to 3 days.