Ear Infections: Types, Symptoms and Treatment

Types of ear infection

The ear has three parts, and infections behave differently in each.

Middle ear infections (otitis media)

A cold or allergy swells the Eustachian tube, which drains the middle ear to the back of the nose. Fluid builds up behind the eardrum and bacteria or viruses multiply in it. Children are prone because their tubes are short, narrow and more horizontal. See acute otitis media for full detail.

When fluid stays after the infection is gone, without pain or fever, it is called otitis media with effusion or glue ear. It can muffle hearing for weeks to months.

Outer ear infections (swimmer's ear)

Moisture, scratching with fingers or cotton swabs, hearing aids and earbuds break down the protective skin of the canal, letting bacteria (usually Pseudomonas or Staphylococcus) in. The hallmark is pain when you tug the earlobe or press the flap in front of the ear. Read more about swimmer's ear.

Inner ear infections

Labyrinthitis causes sudden spinning vertigo with hearing loss or ringing, often after a viral illness. It does not usually cause ear pain. Vestibular neuritis is similar but spares hearing.

Ear infection symptoms

In children

• Ear pain, often worse lying down
• Pulling at the ears, crying more than usual, poor sleep
• Fever, often 38 to 39 °C (100.4 to 102.2 °F)
• Fussiness, poor feeding, not responding to quiet sounds
• Fluid draining from the ear if the eardrum bursts, often with sudden relief of pain

In adults

Adults get middle ear infections less often. Symptoms are ear pain, a blocked or full feeling, muffled hearing and sometimes fever. Outer ear infections are more common in adults and cause itch, pain on touching the ear and ear discharge.

Causes and risk factors

• Colds and flu (the most common trigger for middle ear infections)
• Age 6 months to 2 years
• Daycare attendance
• Exposure to cigarette smoke
• Bottle-feeding lying flat, and pacifier use after 6 months
• Allergies and enlarged adenoids
• Cleft palate and Down syndrome
• Swimming, humid weather and cleaning ears with swabs (outer ear)

How ear infections are diagnosed

A doctor looks in the ear with an otoscope. In a middle ear infection, the eardrum is red, bulging and does not move normally when a puff of air is applied. In an outer ear infection, the canal is red, swollen and may contain debris, while the eardrum is often normal. Hearing tests are done if hearing stays muffled. CT scans are only needed for suspected complications.

Treatment

Pain relief for all types

Use acetaminophen (paracetamol) or ibuprofen, following the label dose for age or weight. Never give aspirin to children or teenagers. A warm compress can help.

Middle ear infections

• Watchful waiting: for children over 6 months with mild symptoms, many guidelines suggest waiting 48 to 72 hours, because most clear without antibiotics.
• Antibiotics: for babies under 6 months, children under 2 with infection in both ears, severe pain, high fever, discharge or symptoms that are not improving. Amoxicillin is the usual first choice.
• Ear tubes: small tubes placed in the eardrum for frequent infections or long-lasting fluid with hearing loss.

Outer ear infections

Antibiotic ear drops, sometimes with a steroid, for 7 days. Keep the ear dry. A wick may be placed if the canal is very swollen. Oral antibiotics are only needed when infection spreads beyond the canal.

Complications

Most ear infections heal without problems. Rarely:

• Eardrum perforation, which usually heals in weeks
• Temporary hearing loss from fluid, which can delay speech if long-lasting
• Mastoiditis, infection of the bone behind the ear
• Meningitis or brain abscess (very rare)
• Malignant otitis externa, a severe skull-base infection in older people with diabetes

Prevention

• Keep vaccines up to date, including pneumococcal and yearly flu shots
• Breastfeed if you can, and avoid bottle-feeding a baby lying flat
• Avoid smoke exposure
• Wash hands to reduce colds
• Dry ears after swimming and do not use cotton swabs in the canal

Frequently asked questions

How long does an ear infection last?

Most middle ear infections improve within 2 to 3 days and clear within a week, with or without antibiotics. Fluid behind the eardrum can linger for weeks after the pain is gone. Outer ear infections usually improve within 2 to 3 days of starting drops and settle within 7 to 10 days.

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

Pain when you pull the earlobe or press the front of the ear points to an outer ear infection, often with itch and discharge after swimming. Deep pain with a cold, fever and muffled hearing points to a middle ear infection. A doctor can tell by looking at the eardrum.

Are ear infections contagious?

The ear infection itself is not contagious. However, the cold or flu viruses that often lead to middle ear infections do spread from person to person. Outer ear infections do not spread between people.

Do ear infections always need antibiotics?

No. Many middle ear infections in children over 6 months clear on their own within 2 to 3 days, so doctors often recommend pain relief and watchful waiting. Antibiotics are given to young babies, severe infections and infections that are not improving. Outer ear infections are treated with drops rather than pills.

Why do adults get ear infections?

Adults get middle ear infections after colds, sinus infections or allergies that block the Eustachian tube, and smokers are more prone. Adults more often get outer ear infections from swimming, earbuds, hearing aids or scratching the canal. Repeated middle ear infections in an adult should be checked by an ENT specialist.