Ear Infection: Symptoms, Causes & Treatment

What Are the Symptoms of an Ear Infection?

The main symptoms of an ear infection include ear pain (especially when lying down), fever, feeling of fullness or pressure in the ear, and reduced hearing. Children under one year often have high fever and severe pain, while older children may have no fever but experience poor appetite, sleep difficulties, and irritability.

Ear infections typically begin suddenly, with symptoms appearing within hours. The pain is often worst at night because lying down increases pressure in the middle ear. Understanding the different symptoms can help you determine when to seek medical care and what level of urgency is appropriate for your situation.

The symptoms of an ear infection can vary significantly depending on the age of the person affected. Infants and young children may not be able to verbalize their discomfort, so it's important for caregivers to recognize the behavioral signs that may indicate an ear infection. Adults, while less commonly affected, often experience more severe symptoms that require prompt medical attention.

The intensity of symptoms also varies based on whether the infection is caused by bacteria or viruses, the extent of inflammation in the middle ear, and whether there is fluid accumulation behind the eardrum. In some cases, the eardrum may rupture due to pressure buildup, which actually provides relief from pain but indicates a more significant infection.

Common Symptoms of Ear Infection

The following symptoms are commonly associated with middle ear infections and should prompt attention, particularly when multiple symptoms occur together or when they persist beyond the expected timeframe:

• Ear pain (otalgia): Sharp, throbbing, or dull pain in one or both ears, typically worse when lying down
• Fever: Temperature elevation, though not always present, especially in older children and adults
• Ear fullness: A sensation of pressure or blockage in the affected ear
• Hearing reduction: Temporary decrease in hearing ability due to fluid behind the eardrum
• Ear drainage: Yellow-white, thick fluid draining from the ear if the eardrum has ruptured

Symptoms in Infants and Young Children

Because infants and toddlers cannot describe their symptoms, parents and caregivers should watch for behavioral changes that may indicate an ear infection. These young children often experience more severe symptoms because their immune systems are still developing and their Eustachian tubes are shorter and more horizontal, making it easier for bacteria to reach the middle ear.

• Pulling or tugging at ears: A classic sign in infants who cannot verbalize pain
• Increased crying and irritability: Especially when lying down or during feeding
• Difficulty sleeping: Waking frequently or refusing to lie down
• Poor feeding or appetite: The sucking motion can increase ear pressure and pain
• Balance problems: Unsteadiness when walking in toddlers
• High fever: Children under one year commonly develop significant fever

When the Eardrum Ruptures

Sometimes the pressure from fluid buildup becomes so great that the eardrum ruptures, creating a small hole that allows the infected fluid to drain. Before rupture, pain is typically very severe, but once the eardrum has perforated, the pain often decreases significantly. While this sounds alarming, a ruptured eardrum usually heals on its own within a few days to a week. However, antibiotic treatment is always required when the eardrum has ruptured to prevent complications and promote healing.

The fluid that drains from a ruptured eardrum is typically yellowish-white and thicker than water. You may notice this discharge on your pillow in the morning or see it coming from the ear canal. This drainage is different from the clear or slightly colored discharge that may occur with swimmer's ear (outer ear infection).

When Should You See a Doctor for an Ear Infection?

See a doctor if ear pain lasts more than 24 hours, occurs with fever, or if there is fluid draining from the ear. Seek immediate emergency care for severe ear pain combined with stiff neck, swelling or redness behind the ear (ear sticking out), high fever with feeling very ill, or symptoms that worsen despite treatment.

While many ear infections resolve on their own, certain situations require prompt medical attention. The challenge for many parents is determining when home care is appropriate and when professional evaluation is necessary. Understanding the warning signs that indicate a more serious infection can help you make informed decisions about seeking care.

The timing and severity of symptoms are key factors in determining the urgency of medical care. An ear infection that has persisted for more than 24 hours warrants evaluation, as does any infection accompanied by high fever or discharge from the ear. In some cases, what appears to be a simple ear infection may actually be part of a more widespread infection requiring different treatment.

Contact Your Doctor If:

The following situations warrant scheduling an appointment with your healthcare provider. These symptoms suggest an infection that may benefit from medical evaluation and potentially antibiotic treatment:

• Ear pain persists for more than 24 hours: Prolonged pain suggests the infection may not be resolving spontaneously
• Ear pain is accompanied by fever: The combination suggests bacterial infection that may need treatment
• Fluid is draining from the ear: Indicates the eardrum has ruptured and antibiotics are needed
• Symptoms persist or worsen 2-3 days after initial evaluation: Even with or without initial treatment
• Ear fullness or hearing loss continues for 3-4 weeks: Suggests persistent fluid that may need intervention
• Ringing or buzzing in the ears persists: May indicate complications requiring specialist evaluation

Special Considerations for Children

Children under 6 months of age require medical evaluation for any suspected ear infection because their immune systems are still developing and infections can progress more rapidly. For children between 6 months and 2 years, any bilateral ear infection (affecting both ears) or infection with moderate to severe symptoms warrants antibiotic treatment. Older children with mild symptoms may be candidates for "watchful waiting" with close follow-up.

What Can You Do at Home for an Ear Infection?

Most ear infections can be managed at home with pain relief medication (acetaminophen or ibuprofen), keeping the head elevated, applying warm compresses, protecting the ear from water, and using saline nasal spray to relieve congestion. Decongestant nasal sprays can ease breathing during a cold but do not treat the ear infection itself.

While waiting for an ear infection to resolve or during the healing process after treatment, several home care measures can help relieve symptoms and support recovery. These approaches focus on managing pain, reducing pressure in the ear, and creating conditions favorable for healing. Even if antibiotics are prescribed, these supportive measures remain valuable.

Pain management is the primary focus of home care for ear infections. The discomfort from an ear infection can be significant, especially in young children, and adequate pain control improves sleep, appetite, and overall well-being during the illness. Additionally, measures to reduce congestion can help improve Eustachian tube function and drainage from the middle ear.

Elevate the Head

Both children and adults feel better when keeping the head elevated during an ear infection. Elevation reduces swelling in the nose and ears and decreases the pain caused by pressure buildup. When sleeping, use extra pillows to keep the head raised.

For infants under one year, you can try holding them in a baby carrier, on your lap, or in a bouncer seat. You can also raise the head of the crib by placing thick books under the legs at the head end. Never place pillows directly in the crib with an infant due to suffocation risk.

Protect the Ear from Water

You should avoid swimming or submerging the head when you have ear pain or when there is drainage from the ear. Getting water in an infected ear can worsen symptoms and introduce additional bacteria. During bathing and showering, take care to keep water out of the affected ear.

If the eardrum has ruptured, you should avoid getting water in the ears for at least one week after the drainage has stopped. During this healing period, use cotton with petroleum jelly or specialized ear plugs when bathing or showering. This protective approach helps ensure proper healing of the eardrum.

Use Nasal Spray for Congestion

Decongestant nasal drops and sprays reduce nasal congestion and can make breathing easier during a cold. However, they do not directly treat the ear infection itself, whether in children or adults. These medications work by shrinking swollen nasal passages, which may indirectly help Eustachian tube drainage.

Do not use decongestant nasal spray for more than 10 days, as prolonged use can cause rebound congestion that is difficult to resolve. Saline nasal spray is a safer alternative for longer-term use and can be particularly helpful for children.

Pain and Fever Medication for Children

Contact your healthcare provider before giving any medication to infants younger than 6 months. For older children, the following guidelines apply:

• Children 3 months and older: Can receive acetaminophen (paracetamol)
• Children 6 months and older: Can receive ibuprofen

These medications are available in child-friendly forms including dissolving tablets and liquid suspensions. Always follow the dosing instructions on the package and do not combine different medications without consulting a healthcare provider. Children and teenagers under 18 should not take aspirin for fever without first consulting a doctor due to the risk of Reye's syndrome.

Pain Medication for Adults

Adults can use over-the-counter pain relievers including acetaminophen (paracetamol) or NSAIDs such as ibuprofen or naproxen. Choose based on your individual health conditions and any contraindications – for example, NSAIDs should be used with caution in people with kidney disease or stomach ulcers.

Are Ear Infections Contagious?

The ear infection itself is not contagious – the bacteria causing it typically do not spread between people. However, ear infections often follow colds, and cold viruses spread very easily. So while you won't "catch" an ear infection directly, you can catch the cold that may lead to one.

Understanding the relationship between colds and ear infections helps explain why ear infections often seem to spread through families and childcare settings. The ear infection develops as a secondary complication when cold viruses compromise the body's defenses and allow bacteria to infect the middle ear. This process is particularly common in young children due to their anatomy and developing immune systems.

The Eustachian tube connects the middle ear to the back of the throat and normally drains fluid and equalizes pressure. During a cold, the tissues lining this tube become swollen and produce excess mucus, which can block normal drainage. This creates a warm, moist environment where bacteria can multiply, leading to infection. Children's Eustachian tubes are shorter, narrower, and more horizontal than adults', making them more susceptible to blockage and bacterial accumulation.

Because the underlying cold is highly contagious, good hygiene practices during illness can help prevent the spread of respiratory viruses and potentially reduce the incidence of ear infections in household contacts. This includes frequent handwashing, covering coughs and sneezes, and avoiding sharing utensils and drinking vessels.

How Can You Prevent Ear Infections?

While not all ear infections can be prevented, you can reduce risk by breastfeeding for at least 6 months, avoiding tobacco smoke exposure, keeping vaccinations current (especially pneumococcal and flu vaccines), holding babies upright during feeding, and practicing good hand hygiene. For children with frequent ear infections, ear tube placement may be recommended.

Prevention strategies for ear infections focus on two main approaches: reducing exposure to the respiratory infections that often precede ear infections, and addressing modifiable risk factors that make some children more susceptible. While adults rarely get ear infections, the preventive measures that reduce respiratory infections are beneficial for overall health.

For parents of young children, particularly those whose children experience recurrent ear infections, understanding and implementing preventive strategies can significantly reduce the frequency and severity of episodes. Some children have anatomical or immunological factors that make them more prone to ear infections, and for these children, additional interventions may be warranted.

Protective Factors

Several factors have been shown to reduce the risk of ear infections in children:

• Breastfeeding: Has a protective effect during the period of breastfeeding, likely due to antibodies and immune factors in breast milk. Exclusive breastfeeding for at least 6 months provides the strongest protection.
• Avoiding tobacco smoke: Children exposed to secondhand smoke have significantly higher rates of ear infections. This includes smoke from cigarettes, cigars, and vaping products.
• Vaccinations: Pneumococcal conjugate vaccine and annual influenza vaccination reduce ear infection rates by preventing the underlying infections that can lead to ear complications.
• Upright feeding position: Holding infants at an angle during bottle feeding prevents milk from pooling in the Eustachian tube area.

Ear Tubes for Recurrent Infections

Children and adults who experience frequent ear infections or persistent fluid behind the eardrum may benefit from having a small tube surgically inserted into the eardrum. This procedure, called tympanostomy or myringotomy with tube placement, is typically performed by an ear, nose, and throat (ENT) specialist.

The tube allows air to enter the middle ear, which reduces the accumulation of fluid behind the eardrum and decreases the risk of new infections. The tube also improves hearing by allowing the eardrum to move freely. Most tubes remain in place for 6-18 months before falling out naturally as the eardrum heals. In some cases, longer-lasting tubes may be used.

The decision to place ear tubes is typically made when a child has had three or more ear infections in 6 months, four or more in a year, or persistent middle ear fluid for more than 3 months affecting hearing. The procedure is brief and performed under general anesthesia in children, with most patients going home the same day.

How Is an Ear Infection Diagnosed?

A doctor diagnoses an ear infection by examining the ear canal and eardrum using an otoscope or ear microscope. The examination reveals whether the eardrum is red, bulging, or has fluid behind it. Additional tests like tympanometry measure eardrum movement and middle ear pressure. These examinations are not painful.

Accurate diagnosis of an ear infection requires visual examination of the ear structures, as symptoms alone cannot definitively distinguish between different types of ear problems. The appearance of the eardrum provides important information about whether infection is present, how severe it is, and whether treatment is needed. Healthcare providers are trained to recognize the characteristic signs that indicate acute otitis media.

The diagnostic process begins with a thorough history of symptoms, including when they started, their severity, and any associated symptoms like cold or fever. This information, combined with the physical examination, helps the provider determine the most appropriate treatment approach.

Otoscopic Examination

To examine the ear, the doctor uses an otoscope (similar to a specialized flashlight) or an ear microscope (similar to binoculars). These instruments illuminate and magnify the eardrum so the doctor can see it clearly. The examination is not painful, though it may feel slightly uncomfortable, especially if the ear canal is inflamed.

During the examination, the doctor looks for signs of infection including redness of the eardrum, bulging due to pressure from fluid behind it, loss of the normal light reflex, and decreased mobility. In cases where the eardrum has ruptured, the doctor may see the perforation and drainage of fluid.

Pneumatic Otoscopy and Tympanometry

To assess eardrum mobility, the doctor may use pneumatic otoscopy, which involves directing small puffs of air toward the eardrum using a special attachment on the otoscope. A healthy eardrum moves freely in response to the air pressure, while a eardrum with fluid behind it moves poorly or not at all.

Alternatively, the doctor may use a tympanometer, which involves placing a small, soft probe in the ear canal opening and measuring how the eardrum responds to pressure changes. The device produces a soft sound while taking measurements. Tympanometry provides objective data about middle ear function and pressure, which can be particularly useful for monitoring chronic conditions or assessing treatment response.

When Specialist Referral Is Needed

In some cases, referral to an ear, nose, and throat (ENT) specialist may be necessary. This is typically recommended if the infection appears particularly serious, if the infection does not respond to treatment, if there are complications, or if ear infections recur frequently. The ENT specialist has additional diagnostic tools and expertise for managing complex ear conditions.

How Are Ear Infections Treated?

Treatment depends on age and severity. Most ear infections in children aged 2-12 years heal on their own without antibiotics. Antibiotics are always needed for: children under 1 year, children under 2 with bilateral infection, all children and adults with ruptured eardrum, those with severe symptoms, and adults with ear infections. Amoxicillin is the first-line antibiotic.

The approach to treating ear infections has evolved significantly based on research showing that many infections resolve spontaneously without antibiotics. This understanding has led to more nuanced treatment guidelines that consider the patient's age, symptom severity, and specific clinical findings. The goal is to treat infections that need antibiotics while avoiding unnecessary antibiotic use that contributes to resistance.

For all patients with ear infections, pain management is an essential component of treatment regardless of whether antibiotics are prescribed. Adequate pain control improves comfort, sleep, and overall well-being during the infection. Parents should not interpret improvement after starting antibiotics as proof the infection was bacterial – many infections would have improved at the same rate without antibiotics.

Who Always Needs Antibiotics?

Current clinical guidelines recommend antibiotic treatment for the following groups:

• Children under 1 year: Higher risk of serious infection and complications
• Children under 2 years with bilateral infection: Both ears affected indicates more significant disease
• Children over 12 years and adults: Ear infections are less common and often more serious in these age groups
• All ages with ruptured eardrum: Indicates more severe infection requiring treatment

When Watchful Waiting May Be Appropriate

For children between approximately 2 and 12 years of age, watchful waiting with pain management may be appropriate if:

• The infection is in one ear only
• Symptoms are mild to moderate
• There is no high fever
• The child is otherwise healthy
• Close follow-up is possible if symptoms worsen

During watchful waiting, the parent or caregiver monitors symptoms closely and has a plan to start antibiotics if symptoms worsen or don't improve within 48-72 hours. Many healthcare providers will write a "safety net" prescription that can be filled if needed.

Why Treatment Varies by Age

The risk of complications from ear infections varies with age. Children between approximately 1 and 5 years often get ear infections that are less severe and more likely to resolve spontaneously. In contrast, infections in very young infants and in adults tend to be more serious and require treatment. This is why the same infection may be treated differently depending on the patient's age.

Antibiotic Treatment

When antibiotics are indicated, amoxicillin is typically the first choice for uncomplicated ear infections. The usual course is 5-10 days depending on age and severity. For patients allergic to penicillin or when first-line treatment fails, alternative antibiotics may be prescribed.

It's important to complete the full course of antibiotics as prescribed, even if symptoms improve before the medication is finished. Stopping antibiotics early can allow resistant bacteria to survive and potentially cause a more difficult-to-treat infection.

Ruptured Eardrum

Regardless of age, antibiotic treatment is always given when the eardrum has ruptured. The perforation indicates a more severe infection. After 2-3 days of treatment, the drainage should stop. The hole in the eardrum typically heals on its own quite quickly, usually within a few days to a week.

Follow-Up Care

Children under 4 years who have had infections in both ears should have a follow-up appointment 3 months after the infection. At this visit, the healthcare provider checks whether fluid remains behind the eardrum, as this can affect hearing. If hearing is not fully restored or the eardrum appears abnormal, referral to an ENT specialist may be warranted.

Older children and adults typically only need follow-up if they continue to have symptoms after the infection has been treated.

What Causes Ear Infections?

Ear infections usually develop during or after a cold when viruses cause swelling and mucus production that blocks the Eustachian tube. This allows bacteria already present in the nose and throat to enter the middle ear and multiply, causing infection. The Eustachian tube anatomy in children makes them particularly susceptible.

Understanding the mechanism by which ear infections develop helps explain why they are so common in young children and why they often follow respiratory infections. The ear is not an isolated structure but is connected to the respiratory system through the Eustachian tube, which serves as both a drainage pathway and a route for potential infection.

The middle ear is the air-filled space behind the eardrum that contains the tiny bones responsible for transmitting sound. Under normal conditions, the Eustachian tube keeps this space properly ventilated and drains any fluid that accumulates. However, when this tube becomes blocked or dysfunctional, the conditions are created for infection to develop.

The Role of Cold Viruses

Cold viruses make it harder for the mucous membranes in the nose and ears to defend against bacteria. The viruses cause inflammation and increased mucus production, which can block the Eustachian tube. With the tube blocked, bacteria that normally live harmlessly in the nose and throat can travel up into the middle ear and cause infection.

Once bacteria are trapped in the middle ear, they multiply in the warm, moist environment. The immune system's response causes additional inflammation, and pus accumulates behind the eardrum. This creates pressure that causes pain and can eventually rupture the eardrum if not relieved.

Why Children Are More Susceptible

Most children get at least one ear infection before age 5-6, but some children get them more frequently. The peak age for ear infections is between 1 and 2 years. Several factors explain why children are more vulnerable:

• Eustachian tube anatomy: Children's Eustachian tubes are shorter, narrower, and more horizontal than adults', making them more easily blocked and allowing bacteria to reach the middle ear more easily
• Immune system development: Young children are still developing immunity to common respiratory pathogens
• Adenoid size: Enlarged adenoids (common in young children) can block the Eustachian tube opening
• Genetic factors: Ear infections can run in families, suggesting inherited susceptibility

What Else Can Cause Ear Pain?

Ear pain can have causes other than middle ear infection, including otitis media with effusion (fluid without infection), outer ear infection (swimmer's ear), and referred pain from dental problems or throat infections. The pattern of symptoms and physical examination helps distinguish between these conditions.

Not all ear pain indicates an acute ear infection, and accurate diagnosis is important because different conditions require different treatments. Several conditions can mimic the symptoms of a middle ear infection or occur alongside it, making proper evaluation by a healthcare provider valuable when symptoms are significant or persistent.

Otitis Media with Effusion (Fluid in the Ear)

Sometimes called "glue ear," this condition involves fluid behind the eardrum without active infection. It commonly occurs after an ear infection has resolved and can persist for weeks to months. Symptoms include hearing loss and a feeling of fullness in the ear, but typically without significant pain or fever. It is common for children to develop this condition after a cold, and it usually resolves on its own. If hearing loss persists, ear tube placement may be recommended.

Outer Ear Infection (Swimmer's Ear)

Also called otitis externa, this is an infection of the ear canal rather than the middle ear. It is often caused by water trapped in the ear, creating conditions for bacterial or fungal growth. Symptoms include pain that worsens when touching the outer ear, itching, and drainage. Treatment involves antibiotic ear drops rather than oral antibiotics. Unlike middle ear infections, swimmer's ear is more common in older children and adults who swim frequently.

What Are the Potential Complications?

Most ear infections heal without complications. Rarely, infection can spread to the bone behind the ear (mastoiditis) or to the brain coverings (meningitis). Signs of complications include severe pain and swelling behind the ear, high fever with severe illness, stiff neck, or facial weakness. These require immediate emergency care.

While the vast majority of ear infections resolve completely without lasting effects, awareness of potential complications helps ensure prompt treatment when needed. Modern antibiotic treatment has made serious complications much rarer than they were historically, but they can still occur, particularly when treatment is delayed or when warning signs are not recognized.

Persistent Fluid After Infection

The most common issue after an ear infection is fluid that remains behind the eardrum for some time after recovery. This can temporarily reduce hearing and may take several weeks to months to fully resolve. You can help speed resolution by performing pressure equalization maneuvers (similar to what you do when flying) several times daily. If significant hearing loss persists for more than 3 months, medical evaluation is warranted.

Mastoiditis

Mastoiditis is a complication in which the infection spreads to the mastoid bone behind the ear. While it is the most common complication of ear infections, it remains very rare overall. Symptoms include severe pain in and behind the ear, fever, and a characteristic appearance where the ear appears to stick out from the head due to swelling behind it.

In young children, this complication can develop so rapidly that the ear infection itself may not have been noticed. Treatment typically requires hospitalization for intravenous antibiotics, and the doctor usually needs to create an opening in the eardrum to drain the pus. Most children recover fully with this treatment, but occasionally a more extensive surgical procedure is required.

Other Rare Complications

In very rare cases, ear infections can lead to additional complications including:

• Facial nerve paralysis: Temporary weakness of the muscles on one side of the face
• Meningitis: Infection of the membranes covering the brain and spinal cord
• Permanent hearing loss: Very rare but can occur with severe or recurrent infections
• Cholesteatoma: An abnormal skin growth in the middle ear that can develop from chronic ear problems