Overview

What is an ear infection?

The commonly used term “ear infection” is known medically as acute otitis media or a sudden infection in the middle ear (the space behind the eardrum). Anyone can get an ear infection — children as well as adults — although ear infections are one of the most common reasons why young children visit healthcare providers.

In many cases, ear infections clear up on their own. Your healthcare provider may recommend a medication to relieve pain. If the ear infection has worsened or not improved, your healthcare provider may prescribe an antibiotic. In children younger than the age of two years, an antibiotic is usually needed for ear infections.

It’s important to see your healthcare provider to make sure the ear infection has healed or if you or your child has ongoing pain or discomfort. Hearing problems and other serious effects can occur with ongoing ear infections, frequent infections and when fluid builds up behind the eardrum.

Where is the middle ear?

The middle ear is behind the eardrum (tympanic membrane) and is also home to the delicate bones that aid in hearing. These bones (ossicles) are the hammer (malleus), anvil (incus) and stirrup (stapes). To provide the bigger picture, let’s look at the whole structure and function of the ear:

Structures of the ear include the external ear, auditory canal, eardrum (tympanic membrane) and the inner ear. The middle ear is the space between the eardrum and the inner ear.

The ear structure and function

There are three main parts of the ear: outer, middle and inner.

The outer ear is the outside external ear flap and the ear canal (external auditory canal).
The middle ear is the air-filled space between the eardrum (tympanic membrane) and the inner ear. The middle ear houses the delicate bones that transmit sound vibrations from the eardrum to the inner ear. This is where ear infections occur.
The inner ear contains the snail-shaped labyrinth that converts sound vibrations received from the middle ear to electrical signals. The auditory nerve carries these signals to the brain.

Other nearby parts

The eustachian tube regulates air pressure within the middle ear, connecting it to the upper part of the throat.
Adenoids are small pads of tissue above the throat and behind the nose and near the eustachian tubes. Adenoids help fight infection caused by bacteria that enters through the mouth.

Who is most likely to get an ear infection (otitis media)?

Middle ear infection is the most common childhood illness (other than a cold). Ear infections occur most often in children who are between age 3 months and 3 years, and are common until age 8. Some 25% of all children will have repeated ear infections.

Adults can get ear infections too, but they don’t happen nearly as often as they do in children.

Risk factors for ear infections include:

Age: Infants and young children (between 6 months of age and 2 years) are at greater risk for ear infections.
Family history: The tendency to get ear infections can run in the family.
Colds: Having colds often increases the chances of getting an ear infection.
Allergies: Allergies cause inflammation (swelling) of the nasal passages and upper respiratory tract, which can enlarge the adenoids. Enlarged adenoids can block the eustachian tube, preventing ear fluids from draining. This leads to fluid buildup in the middle ear, causing pressure, pain and possible infection.
Chronic illnesses: People with chronic (long-term) illnesses are more likely to develop ear infections, especially patients with immune deficiency and chronic respiratory disease, such as cystic fibrosis and asthma.
Ethnicity: Native Americans and Hispanic children have more ear infections than other ethnic groups.

Symptoms and Causes

What causes an ear infection?

Ear infections are caused by bacteria and viruses. Many times, an ear infection begins after a cold or other respiratory infection. The bacteria or virus travel into the middle ear through the eustachian tube (there’s one in each ear). This tube connects the middle ear to the back of the throat. The bacteria or virus can also cause the eustachian tube to swell. This swelling can cause the tube to become blocked, which keeps normally produced fluids to build up in the middle ear instead of being able to be drained away.

Adding to the problem is that the eustachian tube is shorter and has less of a slope in children than in adults. This physical difference makes these tubes easier to become clogged and more difficult to drain. The trapped fluid can become infected by a virus or bacteria, causing pain.

Medical terminology and related conditions

Because your healthcare provider may use these terms, it’s important to have a basic understanding of them:

Acute otitis media (middle ear infection): This is the ear infection just described above. A sudden ear infection, usually occurring with or shortly after cold or other respiratory infection. The bacteria or virus infect and trap fluid behind the eardrum, causing pain, swelling/bulging of the eardrum and results in the commonly used term “ear infection.” Ear infections can occur suddenly and go away in a few days (acute otitis media) or come back often and for long periods of time (chronic middle ear infections).
Otitis media with effusion: This is a condition that can follow acute otitis media. The symptoms of acute otitis media disappear. There is no active infection but the fluid remains. The trapped fluid can cause temporary and mild hearing loss and also makes an ear infection more likely to occur. Another cause of this condition is a block in the eustachian tube not related to the ear infection.
Chronic suppurative otitis media: This is a condition in which the ear infection won’t go away even with treatment. Over time, this can cause a hole to form in the eardrum.

What are the symptoms of otitis media (middle ear infection)?

Symptoms of ear infection include:

Ear pain: This symptom is obvious in older children and adults. In infants too young to speak, look for signs of pain like rubbing or tugging ears, crying more than usual, trouble sleeping, acting fussy/irritable.
Loss of appetite: This may be most noticeable in young children, especially during bottle feedings. Pressure in the middle ear changes as the child swallows, causing more pain and less desire to eat.
Irritability: Any kind of continuing pain may cause irritability.
Poor sleep: Pain may be worse when the child is lying down because the pressure in the ear may worsen.
Fever: Ear infections can cause temperatures from 100° F (38 C) up to 104° F. Some 50% of children will have a fever with their ear infection.
Drainage from the ear: Yellow, brown, or white fluid that is not earwax may seep from the ear. This may mean that the eardrum has ruptured (broken).
Trouble hearing: Bones of the middle ear connect to the nerves that send electrical signals (as sound) to the brain. Fluid behind the eardrums slows down movement of these electrical signals through the inner ear bones.

Diagnosis and Tests

How is an ear infection diagnosed?

Ear exam

Your healthcare provider will look at your or your child’s ear using an instrument called an otoscope. A healthy eardrum will be pinkish gray in color and translucent (clear). If infection is present, the eardrum may be inflamed, swollen or red.

Your healthcare provider may also check the fluid in the middle ear using a pneumatic otoscope, which blows a small amount of air at the eardrum. This should cause the eardrum to move back and forth. The eardrum will not move as easily if there is fluid inside the ear.

Another test, tympanometry, uses air pressure to check for fluid in the middle ear. This test doesn’t test hearing. If needed, your healthcare provider will order a hearing test, performed by an audiologist, to determine possible hearing loss if you or your child has had long lasting or frequent ear infections or fluid in the middle ears that is not draining.

Other checks

Your healthcare provider will also check your throat and nasal passage and listen to your breathing with a stethoscope for signs of upper respiratory infections.

Management and Treatment

How is an ear infection treated?

Treatment of ear infections depends on age, severity of the infection, the nature of the infection (is the infection a first-time infection, ongoing infection or repeating infection) and if fluid remains in the middle ear for a long period of time.

Your healthcare provider will recommend medications to relieve you or your child’s pain and fever. If the ear infection is mild, depending on the age of the child, your healthcare provider may choose to wait a few days to see if the infection goes away on its own before prescribing an antibiotic.

Antibiotics

Antibiotics may be prescribed if bacteria are thought to be the cause of the ear infection. Your healthcare provider may want to wait up to three days before prescribing antibiotics to see if a mild infection clears up on its own when the child is older. If your or your child’s ear infection is severe, antibiotics might be started right away.

The American Academy of Pediatrics has recommended when to prescribe antibiotics and when to consider waiting before prescribing based on your child’s age, severity of their infection, and your child’s temperature. Their recommendations are shown in the table below.

American Academy of Pediatrics Treatment Guide for Acute Otitis Media (AOM)

Child’s Age	Severity of AOM / Temperature	Treatment
6 months and older; in one or both ears	Moderate to severe for at least 48 hours or temp of 102.2° F or higher	Treat with antibiotic
6 months through 23 months; in both ears	Mild for < 48 hours and temp < 102.2	Treat with antibiotic
6 months to 23 months; in one ear	Mild for < 48 hours and temp < 102.2° F	Treat with antibiotic OR observe. If observe, start antibiotics if child worsens or doesn’t improve within 48 to 72 hours of start of symptoms
24 months or older; in one or both ears	Mild for < 48 hours and temp < 102.2° F	Treat with antibiotic OR observe. If observe, start antibiotics if child worsens or doesn’t improve within 48 to 72 hours of start of symptoms

If your healthcare provider prescribes an antibiotic, take it exactly as instructed. You or your child will start feeling better a few days after starting treatment. Even if you feel better and when pain has gone away, don’t stop taking the medication until you were told to stop. The infection can come back if you don’t take all of the medication. If the antibiotic prescribed for your child is a liquid, be sure to use a measuring spoon designed for liquid medications to be sure that you give the right amount.

A hole or tear in your eardrum caused by a severe infection or an ongoing infection (chronic suppurative otitis media) is treated with antibiotic eardrops and sometimes by using a suctioning device to remove fluids. Your healthcare provider will give you specific instructions about what to do.

Pain-relieving medications

Over-the-counter acetaminophen (Tylenol®) or ibuprofen (Advil®, Motrin®) can help relieve earache or fever. Pain-relieving eardrops can also be prescribed. These medications usually start to lessen the pain within a couple hours. Your healthcare provider will recommend pain-relieving medications for you or your child and provide any additional instructions.

Never give aspirin to children. Aspirin can cause a life-threatening condition called Reye’s Syndrome.

Earaches tend to hurt more at bedtime. Using a warm compress on the outside of the ear may also help relieve pain. (This is not recommended for infants.)

Ear tubes (tympanostomy tubes)

Sometimes ear infections can be ongoing (chronic), frequently recurring or the fluid in the middle ear can even remain for months after the infection has cleared (otitis media with effusion). Most children will experience an ear infection by age 5 and some children may have frequent ear infections. Telltale signs of an ear infection in a child can include pain inside the ear, a sense of fullness in the ear, muffled hearing, fever, nausea, vomiting, diarrhea, crying, irritability and tugging at the ears (especially in very young children). If your child has experienced frequent ear infections (three ear infections in six months or four infections in a year), had ear infections that weren’t resolved with antibiotics, or experienced hearing loss from fluid buildup behind the eardrum, you may be a candidate for ear tubes. Ear tubes can provide immediate relief and are sometimes recommended for small children who are developing their speech and language skills. You may be referred to an ear, nose and throat (ENT) specialist for this outpatient surgical procedure, which is called a myringotomy with placement of tube. During the procedure, a small metal or plastic tube is inserted through a tiny incision (cut) in the eardrum. The tube lets air into the middle ear and allows fluid to drain. The procedure is very short — approximately 10 minutes — and there’s a low complication rate with this procedure. This tube usually stays in place from six to 12 months. It often falls out on its own, but it can also be removed by your doctor. The outer ear will need to be kept dry and free of dirty water, like lake water, until the hole in the eardrum heals completely and closes.

What are the harms of fluid buildup in your ears or repeated or ongoing ear infections?

Most ear infections don’t cause long-term problems, but when they do happen, complications can include:

Loss of hearing: Some mild, temporary hearing loss (muffling/distortion of sound) usually occurs during an ear infection. Ongoing infections, infections that repeatedly occur, damage to internal structures in the ear from a buildup of fluid can cause more significant hearing loss.
Delayed speech and language development: Children need to hear to learn language and develop speech. Muffled hearing for any length of time or loss of hearing can significantly delay or hamper development.
Tear in the eardrum: A tear can develop in the eardrum from pressure from the long-lasting presence of fluid in the middle ear. About 5% to 10% of children with an ear infection develop a small tear in their eardrum. If the tear doesn’t heal on its own, surgery may be needed. If you have drainage/discharge from your ear, do not place anything into your ear canal. Doing so can be dangerous if there is an accident with the item touching the ear drum.
Spread of the infection: Infection that doesn’t go away on its own, is untreated or is not fully resolved with treatment may spread beyond the ear. Infection can damage the nearby mastoid bone (bone behind the ear). On rare occasions, infection can spread to the membranes surrounding the brain and spinal cord (meninges) and cause meningitis.

Prevention

What can I do to prevent ear infections in myself and my child?

Here are some ways to reduce risk of ear infections in you or your child:

Don’t smoke. Studies have shown that second-hand smoking increases the likelihood of ear infections. Be sure no one smokes in the house or car — especially when children are present — or at your day care facility.
Control allergies. Inflammation and mucus caused by allergic reactions can block the eustachian tube and make ear infections more likely.
Prevent colds. Reduce your child's exposure to colds during the first year of life. Don’t share toys, foods, drinking cups or utensils. Wash your hands frequently. Most ear infections start with a cold. If possible, try to delay the use of large day care centers during the first year.
Breastfeed your baby. Breastfeed your baby during the first 6 to 12 months of life. Antibodies in breast milk reduce the rate of ear infections.
Bottle feed baby in upright angle. If you bottle feed, hold your baby in an upright angle (head higher than stomach). Feeding in the horizontal position can cause formula and other fluids to flow back into the eustachian tubes. Allowing an infant to hold his or her own bottle also can cause milk to drain into the middle ear. Weaning your baby from a bottle between nine and 12 months of age will help stop this problem.
Watch for mouth breathing or snoring. Constant snoring or breathing through the mouth may be caused by large adenoids. These may contribute to ear infections. An exam by an otolaryngologist, and even surgery to remove the adenoids (adenoidectomy), may be necessary.
Get vaccinations. Make sure your child’s immunizations are up to date, including yearly influenza vaccine (flu shot) for those 6 months and older. Ask your doctor about the pneumococcal, meningitis and other vaccines too. Preventing viral infections and other infections help prevent ear infections.

Outlook / Prognosis

What should I expect if I or my child has an ear infection?

Ear infections are common in children. Adults can get them too. Most ear infections are not serious. Your healthcare provider will recommend over-the-counter medications to relieve pain and fever. Pain relief may begin as soon as a few hours after taking the drug.

Your healthcare provider may wait a few days before prescribing an antibiotic. Many infections go away on their own without the need for antibiotics. If you or your child receives an antibiotic, you should start to see improvement within two to three days.

If you or your child has ongoing or frequent infections, or if fluid remains in the middle ear and puts hearing at risk, ear tubes may be surgically implanted in the eardrum to keep fluid draining from the eustachian tube as it normally should.

Never hesitate to contact your healthcare provider if you have any concerns or questions.

Living With

When should I return to my healthcare provider for a follow-up visit?

Your healthcare provider will let you know when you need to return for a follow-up visit. At that visit, you or your child’s eardrum will be examined to be certain that the infection is going away. Your healthcare provider may also want to test you or your child's hearing.

Follow-up exams are very important, especially if the infection has caused a hole in the eardrum.

When should I call the doctor about an ear infection?

Call your healthcare provider immediately if:

You or your child develops a stiff neck.
Your child acts sluggish, looks or acts very sick, or does not stop crying despite all efforts.
Your child’s walk is not steady; he or she is physically very weak.
You or your child’s ear pain is severe.
You or your child has a fever over 104° F (40° C).
Your child is showing signs of weakness in their face (look for a crooked smile).
You see bloody or pus-filled fluid draining from the ear.

Call your healthcare provider during office hours if:

The fever remains or comes back more than 48 hours after starting an antibiotic.
Ear pain is not better after three days of taking an antibiotic.
Ear pain is severe.
You have any questions or concerns.

Why do children get many more ear infections than adults? Will my child always get ear infections?

Children are more likely than adults to get ear infections for these reasons:

The eustachian tubes in young children are shorter and more horizontal. This shape encourages fluid to gather behind the eardrum.
The immune system of children, which in the body’s infection-fighting system, is still developing.
The adenoids in children are relatively larger than they are in adults. The adenoids are the small pads of tissue above the throat and behind the nose and near the eustachian tubes. As they swell to fight infection, they may block the normal ear drainage from the eustachian tube into the throat. This blockage of fluid can lead to a middle ear infection.

Most children stop getting ear infections by age 8.

Do I need to cover my ears if I go outside with an ear infection?

No, you do not need to cover your ears if you go outside.

Can I swim if I have an ear infection?

Swimming is okay as long as you don’t have a tear (perforation) in your eardrum or have drainage coming out of your ear.

Can I travel by air or be in high altitudes if I have an ear infection?

Air travel or a trip to the mountains is safe, although temporary pain is possible during takeoff and landing when flying. Swallowing fluids, chewing on gum during descent, or having a child suck on a pacifier will help relieve discomfort during air travel.

Are ear infections contagious?

No, ear infections are not contagious.

When can my child return to normal daily activities?

Children can return to school or day care as soon as the fever is gone.

What are other causes of ear pain?

Other causes of ear pain include:

A sore throat.
Teeth coming in in a baby.
An infection of the lining of the ear canal. This is also called “swimmer’s ear.”
Pressure build up in the middle ear caused by allergies and colds.

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Ear Infection (Otitis Media)