Middle Ear Infection (Otitis Media)

How a middle ear infection develops

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

Children are more prone because their Eustachian tubes are shorter, narrower and more horizontal, and their adenoids may block the tubes.

Symptoms

In babies and young children

• tugging or pulling at the ear (pulling at ears)
• crying, irritability and fussiness, especially lying down
• trouble sleeping
• fever
• poor feeding, as sucking and swallowing hurt
• fluid draining from the ear
• not responding to quiet sounds
• loss of balance

In older children and adults

• ear pain, often sudden and throbbing
• muffled hearing or a full feeling in the ear
• fever
• sometimes dizziness or ringing in the ear

If the eardrum bursts, pain often eases suddenly and pus or blood drains from the ear. The small hole usually heals within weeks.

Types of otitis media

Risk factors

• age 6 months to 3 years
• attending daycare
• exposure to cigarette smoke
• bottle feeding while lying flat; pacifier use
• colds, allergies and enlarged adenoids
• family history
• cleft palate and Down syndrome
• autumn and winter

Breastfeeding and up-to-date pneumococcal and flu vaccines lower the risk.

Ear infections in adults

Middle ear infections are less common in adults and usually follow a cold, allergies or air travel. Repeated infections, or persistent fluid in one ear without a clear cause, should be examined by an ENT specialist to rule out a blockage at the back of the nose.

Diagnosis

A clinician looks at the eardrum with an otoscope. A bulging, red or cloudy eardrum that does not move well confirms acute infection. Fluid without bulging suggests otitis media with effusion. Tympanometry and hearing tests are used for persistent fluid or hearing concerns.

Treatment

Pain relief

Acetaminophen (paracetamol) or ibuprofen at the correct dose for age and weight is the first treatment. Do not give aspirin to children or teenagers. Ibuprofen is not used under 6 months unless a doctor advises.

Watchful waiting

Many ear infections resolve without antibiotics within 2 to 3 days. For children over 6 months with mild symptoms (and over 2 years with infection in one or both ears), doctors may suggest waiting 48 to 72 hours with pain relief, starting antibiotics only if symptoms do not improve or get worse.

Antibiotics

Antibiotics, usually amoxicillin, are recommended for:

• babies under 6 months
• children 6 to 23 months with infection in both ears or severe symptoms
• severe pain, fever of 39 °C (102.2 °F) or higher, or illness lasting more than 48 hours
• discharge from the ear
• symptoms that do not improve with watchful waiting

Finish the full course as prescribed.

Recurrent infections

Children with frequent infections or long-lasting fluid with hearing loss may benefit from ear tubes (tympanostomy tubes), small tubes placed in the eardrum to ventilate the middle ear. Adenoid removal may help some children.

Complications

Uncommon but possible:

• temporary hearing loss, which can affect speech development if prolonged
• eardrum perforation
• mastoiditis: infection of the bone behind the ear
• cholesteatoma after repeated infections
• rarely, meningitis or brain abscess

Prevention

• keep vaccinations up to date, including pneumococcal and annual flu vaccines
• avoid smoke exposure
• breastfeed if possible, and hold babies upright when bottle feeding
• wash hands to reduce colds

Frequently asked questions

What are the symptoms of a middle ear infection?

Common symptoms are ear pain, fever and muffled hearing. Young children may pull at their ears, cry more, sleep poorly, feed poorly and be unusually irritable. Fluid draining from the ear may mean the eardrum has burst.

Do ear infections need antibiotics?

Not always. Many ear infections clear on their own in 2 to 3 days. Antibiotics are recommended for babies under 6 months, severe or bilateral infections in young children, high fever, ear discharge, or infections that do not improve after 48 to 72 hours.

How long does a middle ear infection last?

Pain usually improves within 2 to 3 days. Fluid can stay behind the eardrum for weeks to a few months after the infection, sometimes muffling hearing, before clearing on its own.

Can adults get middle ear infections?

Yes, though less often than children. In adults they usually follow a cold or allergies. Repeated infections or persistent one-sided fluid should be assessed by an ENT specialist.

Are ear infections contagious?

The ear infection itself is not contagious, but the cold viruses that often cause it are. Good handwashing helps prevent spread.