ConditionEar, nose & throat
Otitis Media (Middle Ear Infection)
Otitis media is inflammation or infection of the middle ear, the air-filled space behind the eardrum. Acute otitis media causes ear pain, fever and a bulging red eardrum, often after a cold, and is one of the most common reasons young children see a doctor. Many cases improve within 2 to 3 days without antibiotics; doctors use age and severity to decide who needs them. Otitis media with effusion is fluid without infection that can muffle hearing for weeks. Frequent infections or persistent fluid may need ear tubes.
Also called: Middle ear infection, ear infection, acute otitis media (AOM), otitis media with effusion (glue ear)
At a glance
- What it is
- Inflammation of the middle ear, usually with infection.
- Who gets it
- Most common between 6 months and 3 years; adults less often.
- Symptoms
- Ear pain, fever, irritability, ear pulling, poor sleep, muffled hearing.
- Treatment
- Pain relief; antibiotics for younger, sicker or persistent cases; watchful waiting for many.
- Recurrent or persistent
- Ear tubes for frequent infections or long-lasting fluid with hearing loss.
When to get help
Call 911 or go to the ER
- Fever with a stiff neck, severe headache, confusion or unusual drowsiness
- Swelling, redness and tenderness behind the ear pushing the ear forward (possible mastoiditis)
- Facial weakness or drooping on the same side as the ear infection
- Severe dizziness and vomiting with ear pain
See a doctor within a day or two
- A baby under 6 months with ear pain or fever, or any baby under 3 months with fever of 38 °C (100.4 °F) or more
- Fever of 39 °C (102.2 °F) or higher, or severe ear pain
- Pus or fluid draining from the ear
- Symptoms not improving after 48 to 72 hours, or getting worse
Book a routine appointment
- 3 or more ear infections in 6 months, or 4 in a year
- Hearing problems, speech delay or ongoing ear fullness for more than 3 months
- Ear infections in an adult that keep returning or affect one side only
Usually safe to manage at home
- Mild ear pain with a cold in a child over 2 who is otherwise well, while managing pain and watching for 48 hours
How middle ear infections happen
The middle ear is connected to the back of the nose by the Eustachian tube, which drains fluid and equalizes pressure. In young children this tube is shorter, flatter and floppier. A cold or allergy swells the tube, fluid becomes trapped behind the eardrum, and bacteria or viruses from the nose multiply in it. Pressure from the inflamed fluid causes pain and a bulging eardrum.
Types of otitis media
| Type | Features |
|---|---|
| Acute otitis media (AOM) | Sudden ear pain, fever, bulging eardrum with fluid and inflammation |
| Otitis media with effusion (OME, glue ear) | Fluid without signs of acute infection; muffled hearing; often after AOM |
| Recurrent AOM | 3 or more episodes in 6 months, or 4 in 12 months |
| Chronic suppurative otitis media | Persistent drainage through a perforated eardrum for weeks |
Symptoms
In babies and young children
- ear pain, often worse lying down
- pulling or rubbing the ear (not always a reliable sign on its own)
- fever
- irritability, crying and poor sleep
- reduced appetite, vomiting or diarrhea
- not responding to quiet sounds
- fluid draining from the ear if the eardrum bursts, often with relief of pain
In older children and adults
- ear pain and a blocked or full feeling
- muffled hearing
- sometimes dizziness or ringing
Causes and risk factors
- colds and other upper respiratory infections, the main trigger
- bacteria: Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis
- age 6 months to 3 years
- daycare attendance
- exposure to tobacco smoke
- bottle-feeding while lying down, pacifier use
- family history
- seasonal allergies and enlarged adenoids
- cleft palate and Down syndrome, which affect Eustachian tube function
Diagnosis
A clinician looks at the eardrum with an otoscope. In AOM the eardrum is red, cloudy and bulging, with reduced movement. Pneumatic otoscopy (a puff of air) and tympanometry assess movement and fluid. Hearing tests are recommended when fluid persists for 3 months or more.
Treatment
Pain relief
Treat pain in every case: acetaminophen (paracetamol) or ibuprofen at the correct dose for age and weight. Do not give aspirin to children or teenagers. Warm compresses can help.
Antibiotics or watchful waiting
Many ear infections resolve on their own within 2 to 3 days. AAP guidance supports antibiotics or watchful waiting depending on age and severity:
| Situation | Usual approach |
|---|---|
| Under 6 months | Antibiotics |
| 6 to 23 months, both ears or severe symptoms | Antibiotics |
| 6 to 23 months, one ear, mild symptoms | Antibiotics or watchful waiting for 48 to 72 hours |
| 2 years and older, mild symptoms | Watchful waiting is an option |
| Severe symptoms (high fever, severe pain, symptoms over 48 hours) | Antibiotics |
| Drainage from the ear | Antibiotics |
Amoxicillin is the usual first choice. Watchful waiting means treating pain and having a plan, sometimes a "safety-net" prescription, to start antibiotics if the child is not improving in 48 to 72 hours.
Otitis media with effusion
Fluid usually clears within 3 months without treatment. Antibiotics, decongestants and antihistamines do not help it. If fluid persists with hearing loss or speech concerns, ear tubes may be advised.
Ear tubes
Tympanostomy tubes are small tubes placed through the eardrum under brief general anesthesia. They ventilate the middle ear, prevent fluid buildup, and allow ear drops to treat infections. They are considered for recurrent AOM with fluid present, or OME lasting 3 months or more with hearing loss. They usually fall out on their own in 6 to 18 months. Adenoid removal may be added in some children.
Complications
- temporary hearing loss and, if prolonged, speech or learning delays
- perforated eardrum, which usually heals within weeks
- mastoiditis: infection of the bone behind the ear
- cholesteatoma with chronic infection
- rarely, meningitis, brain abscess or facial nerve palsy
Prevention
- keep vaccinations up to date, including pneumococcal and yearly flu vaccines
- breastfeed for at least 6 months if possible
- avoid tobacco smoke exposure
- do not bottle-feed lying flat
- reduce pacifier use after 6 months
- hand washing to reduce colds
Otitis media in adults
Ear infections are less common in adults and are often linked to Eustachian tube dysfunction, allergies or sinus disease. Persistent fluid in one ear in an adult, especially with a blocked nose on the same side, should be examined to rule out a growth at the back of the nose.
Frequently asked questions
What are the symptoms of a middle ear infection?
Common symptoms are ear pain, fever, muffled hearing and a full feeling in the ear. Young children may be irritable, pull at their ear, sleep poorly and eat less. Fluid may drain from the ear if the eardrum bursts.
Do all ear infections need antibiotics?
No. Many middle ear infections, especially in children over 2 with mild symptoms, get better on their own within 2 to 3 days. Antibiotics are recommended for babies under 6 months, young children with severe or two-sided infections, and those not improving after 48 to 72 hours.
How long does otitis media last?
Pain usually improves within 1 to 3 days. Fluid behind the eardrum can last several weeks after the infection clears, causing muffled hearing, and usually resolves within 3 months.
When does a child need ear tubes?
Ear tubes are considered for children with frequent ear infections, such as 3 in 6 months or 4 in a year, with fluid present, or for fluid lasting 3 months or more with hearing loss or speech concerns.
Are ear infections contagious?
The middle ear infection itself is not contagious, but the colds that lead to it are. Hand washing and vaccinations reduce the chance of the infections that trigger ear infections.
Sources
This guide was written from current patient and clinical guidance, including:
- American Academy of Pediatrics: Clinical practice guideline: the diagnosis and management of acute otitis media
- American Academy of Otolaryngology-Head and Neck Surgery: Clinical practice guideline: otitis media with effusion; tympanostomy tubes in children
- CDC: Ear infection basics
- MedlinePlus: Ear infection, acute
- NHS: Ear infections