Middle ear infection (otitis media)

Most ear infections occur in infants aged 6-18 months, though anyone can get an ear infection.

Information written and reviewed by Certified Doctors.

Contents

Introduction

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Otitis media is an infection of the middle ear common in younger children.

Most ear infections occur in infants aged 6-18 months, though anyone can get an ear infection. For reasons that are unclear they are more common in boys than girls.

Signs that your child might have an ear infection include:

  • pulling, tugging, or rubbing their ear
  • a high temperature (38°C or above)
  • irritability
  • poor feeding
  • restlessness at night
  • coughing
  • runny nose
  • unresponsiveness to quiet sounds
  • loss of balance

Read more about the signs and symptoms of otitis media.

When to seek medical advice

Most ear infections clear up quickly so it is not always necessary to see your doctor.

However, it is recommended that you contact your doctor for advice if:

  • symptoms show no sign of improvement after 24 hours
  • your child seems to be in a lot of pain
  • you notice fluid coming from the ear

You should also contact your doctor if your child is more vulnerable to the effects of infection, for example due to certain medical conditions.

Treating an ear infection

Most ear infections clear up within a couple of days. Paracetamol or ibuprofen (appropriate for the child's age) can be used to relieve pain and high temperature.

Antibiotics are usually only required if symptoms persist or are particularly severe.

Read more about the treatment of otitis media.

What causes an ear infection?

The middle ear is directly behind the eardrum. It is made up of three tiny lever-like bones that carry sound vibrations from the eardrum to the inner ear.

Most cases of otitis media are caused by a bacterial or viral infection. Often an infection of the respiratory tract (sinuses, throat, airways or lungs) such as the cold or flu can spread into the middle ear.

Younger children are particularly vulnerable to this type of infection as their middle ear is smaller and narrower than an adults' which makes it easier for an infection to take hold.

The risk of developing an ear infection is increased if your child:

  • attends a nursery or day care centre – this increases exposure to infection from other children
  • is exposed to passive smoking
  • is not breastfed

Read more about the causes of ear infection.

Complications

Complications of ear infections are uncommon but when they do occur they can be troublesome and include:

  • infection spreading into the bones underneath the ear (the mastoids) which is known as mastoiditis
  • the infection spreads into the protective membranes that surround the brain and spinal cord (the meninges), which is known as meningitis

Read more about the complications of otitis media.

Symptoms

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In most cases the symptoms of an ear infection (otitis media) develop quickly and resolve in a few days – often referred to as acute otitis media.

Main symptoms of acute otitis media include:

  • earache
  • a high temperature (fever) of 38°C (100.4°F) or higher
  • being sick
  • lack of energy
  • slight deafness

Babies with ear infections will be hot and irritable. As babies are unable to communicate the source of their discomfort, it can be difficult to tell what is wrong with them. However, your baby may have an ear infection if they are unsettled in this way.

Other signs to look for in younger children include:

  • pulling, tugging or rubbing their ear
  • irritability
  • poor feeding
  • restlessness at night
  • coughing
  • a runny nose
  • diarrhoea
  • unresponsiveness to quiet sounds or other signs of difficulty hearing, such as sitting too close to the television or inattentiveness
  • loss of balance

Sometimes, in cases of middle ear infection, the eardrum will become perforated (a hole will form in it) and pus may run out of the ear. This can help to relieve the pain by releasing the pressure on the eardrum, but it may also lead to re-infection.

When to seek medical advice

Speak to your doctor if your child’s symptoms show no sign of improvement after 24 hours, they seem to be in a lot of pain, or you notice a discharge of pus or fluid from their ear.

Long term ear infection

Ear infections that last for many months are known as chronic suppurative otitis media (CSOM). This condition is less common, affecting around 1 in 100 children and 1 in 50 adults.

The most common symptom of CSOM is a persistent and usually painless drainage from the affected ear.

Some degree of hearing loss in the affected ear is also common.

Glossary

Acute means occurring suddenly or over a short period of time.

Pain is an unpleasant physical or emotional feeling that your body produces as a warning sign that it has been damaged.

A high temperature, also known as a fever, is when someone's body temperature rises above the normal 37°C (98.6°F).

Vomiting is when you bring up the contents of your stomach through your mouth.

Chronic usually means a condition that continues for a long time or keeps coming back.

Causes

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Most cases of otitis media (middle ear infection) are caused when a bacterial or viral infection, such as a cold, spreads into a part of the ear known as the Eustachian tube.

The Eustachian tube is a thin tube that runs from the middle ear to the back of the nose. It has two main functions, the first, to ventilate the middle ear, helping to maintain normal air pressure. The second, to help drain away mucus and other debris from the ear.

An infection in another part of the body can cause the Eustachian tube to become blocked, leading to an infection.

Enlarged tonsils or adenoids (small lumps of tissue at the back of the throat, above the tonsils) may block the Eustachian tube. Adenoids and tonsils can be removed if they cause a persistent or frequently reoccurring ear infection, this is more common in children than in adults.

Read more about removing tonsils and removing adenoids.

A child's Eustachian tube is smaller than an adult's, which makes it more likely to become blocked. A child’s adenoids are much larger than an adult’s in relative terms.

Other things that can increase the risk of developing an ear infection include:

  • attending a nursery or day care centre – this increases a child’s likely exposure to infection from other children
  • being exposed to tobacco smoke (passive smoking)
  • not being breastfed

Glossary

Body tissue is made up of groups of cells that perform a specific job, such as protecting the body against infection, producing movement or storing fat.

The immune system is the body's defence system, which helps protect it from disease, bacteria and viruses.

Bacteria are tiny, single-celled organisms that live in the body. Some cause illness and disease and others are good for you.

Chronic usually means a condition that continues for a long time or keeps coming back.

Diagnosis

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An ear infection (otitis media) can usually be diagnosed using a tool known as a pneumatic otoscope.

A pneumatic otoscope is a small, hand-held device that has a magnifying glass and a light source at the end. It is used to study the inside of the ear.

An otoscope can detect certain signs that would indicate fluid in the middle ear, which in turn may indicate an infection.

These include the ear drum:

  • being pulled inwards
  • being an unusual colour
  • having a cloudy appearance, and bubbles and fluid inside the ear

The otoscope can also be used to blow a small puff of air into the ear. If the Eustachian tube (a tube that passes between your throat and middle ear) is clear, the eardrum will move slightly. If it is blocked, the eardrum will remain still. The examination will also show whether the eardrum is perforated (has a hole in it).

Other tests

Other tests are usually only required if treatment is not working or complications develop.

These tests are described below.

Tympanometry

Tympanometry measures how the ear drum reacts to changes in air pressure. A healthy ear drum should move easily if there is a change in air pressure.

During a tympanometry test, a probe placed into ear changes the air pressure at regular intervals while transmitting a sound into the ear.

The probe measures how sound reflects back from the ear, and how changes in air pressure affect these measurements. If less sound is reflected back when the air pressure is high, it usually indicates an infection.

Tympanocentesis

Tympanocentesis involves draining fluid out of the middle ear using a small needle. The fluid can then be tested for bacteria or viruses that could be responsible for the infection.

CT scans

A computer tomography (CT) scan may be used if it is thought the infection may have spread out of the middle ear.

A CT scan takes a series of X-rays and uses a computer to assemble the scans into a more detailed, ‘3D’ image of the skull.

Treatment

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Most cases of middle ear infection (otitis media) will clear up within 72 hours without the need for treatment.

You can relieve your child’s symptoms of earache and high temperature using over-the-counter painkillers such as ibuprofen and paracetamol.

Aspirin should not be given to children under 16 years of age.

Placing a warm flannel or washcloth over the affected ear may also help relieve pain.

Antibiotics

The routine use of antibiotics to treat ear infection is not recommended because:

  • there is no evidence they speed up the healing process
  • many middle ear infections are caused by viral infections so antibiotics are often ineffective
  • every time you use antibiotics to treat a non-serious infection it increases the likelihood of bacteria becoming resistant to it, meaning more serious infections could become untreatable (read more about antibiotic resistance)

Antibiotics are usually only recommended if:

  • your child has a serious health condition that makes them more vulnerable to infection such as cystic fibrosis or congenital heart disease
  • your child is under the age of three months
  • your child’s symptoms show no signs of improvement after four days

If antibiotics are needed, then a five day course of an antibiotic called amoxicillin is usually prescribed. This is usually given as a liquid suspension which your child has to drink.

Common side effects of amoxicillin include:

If your child is allergic to amoxicillin, alternative antibiotics such as erythromycin can be used.

Adults who develop a long-term middle ear infection (chronic suppurative otitis media) may benefit from antibiotic ear drops.

Additional treatment

Additional treatment is usually only needed if your child has frequent, reoccurring middle ear infections. These treatments are outlined below.

Grommets

For children with recurrent, severe middle ear infections, tiny tubes may be inserted through the eardrum to help drain fluid. These tubes are called grommets or tympanostomy tubes.

A grommet insertion is performed under general anaesthetic (where the patient is unconscious). It usually only takes about 15 minutes, so your child should be able to go home the same day.

As the ear recovers from the effects of the infection it will slowly push the grommet tube outwards and it will eventually fall out of the ear.

This process happens naturally and should not be painful.

Most grommets will fall out from 9 to 15 months after being inserted. Around one child in three will need further grommets.

Myringotomy

A myringotomy is a surgical procedure where the surgeon makes a tiny cut into the eardrum.

This can help relieve pressure on the middle ear and allows the surgeon to drain away excess fluid inside the middle ear.

In some cases a myringotomy may then be followed with a grommet insertion.

Glossary

Chronic usually means a condition that continues for a long time or keeps coming back.

Antibiotics are medicines used to treat infections caused by micro-organisms, usually bacteria or fungi. For example amoxicillin, streptomycin and erythromycin.

Pain is an unpleasant physical or emotional feeling that your body produces as a warning sign it has been damaged.

A high temperature, also known as a fever, is when someone's body temperature rises above the normal 37°C (98.6°F).

Antihistamine medicine counteracts the action of histamine (a chemical released during an allergic reaction). For example loratadine, hydroxyzine.

Inflammation is the body's response to infection, irritation or injury, which causes redness, swelling, pain and sometimes a feeling of heat in the affected area.

Acute means occurring suddenly or over a short period of time.

Decongestant medicine relieves congestion by reducing the swelling of the lining of the nose and sinuses and drying up the mucus.

Complications

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Complications of middle ear infection (otitis media) are now less common than they were in the past.

Very young children may have an increased risk of developing complications as their immune systems (the body’s defence against infection) are still developing.

Some of the most commonly reported complications are detailed below.

Mastoiditis

Mastoiditis is one of the most common complications of otitis media (though still rare in general terms) and is caused when the infection spreads out of the middle ear and into the area of bone underneath the ear (the mastoids).

Symptoms of mastoiditis include:

  • earache
  • a drainage of fluid from the ear
  • a high temperature of 38C (100.4F), or above
  • hearing loss
  • headache
  • redness and swelling in, and sometimes behind the ear

Mastoiditis is treated by injecting antibiotics directly into the mastoid bone. In some cases surgery may be required to remove a damaged section of bone and drain fluid out of the middle ear.

Cholesteatoma

Cholesteatoma is an abnormal pocket of skin (cyst) that can sometimes develop as a complication of reoccurring or persistent middle ear infections.

Symptoms of a cholesteatoma include:

  • dizziness
  • hearing loss in the affected ear
  • drainage of fluid from the ear

Surgery is usually required to remove the cyst.

Labyrinthitis

In some cases the infection can move into the inner ear causing a delicate structure deep inside the ear, called the labyrinth, to become inflamed. This is known as labyrinthitis.

Symptoms of labyrinthitis include:

  • dizziness
  • vertigo – the feeling that the world is moving or spinning around you
  • loss of balance
  • hearing loss

Treatment options include taking a medication called prochlorperazine to combat symptoms of vertigo and dizziness and taking antibiotics to treat the underlying infection.

Read more about the treatment of labyrinthitis.

Facial paralysis

In rare cases the swelling associated with otitis media can cause the facial nerve to become compressed.

The facial nerve is a section of nerve that runs through the skull and is used by the brain to control facial expression.

Compression of the nerve can lead to people being unable to move some, or all, of their face, which is known as facial paralysis.

This complication can be frightening when it first occurs as many parents are concerned their child may have experienced a stroke or similar. But the condition usually resolves once the underlying infection has passed and rarely causes any long-term problems.

Meningitis

A rare and serious complication of otitis media is that the infection spreads to the protective outer layer of the brain and spinal cord (the meninges) leading a serious infection known as meningitis.

Symptoms of meningitis include:

  • severe headache
  • being sick
  • high temperature (fever) of 38ºC (100.4ºF) or over
  • stiff neck
  • sensitivity to light
  • a blotchy red rash that does not fade or change colour when you place a glass against it – the rash is not always present

Bacterial meningitis is a medical emergency. If you think your child may have meningitis call for an ambulance.

Bacterial meningitis is treated using injections of antibiotics. Read more about the treatment of meningitis.

Brain abscess

Another rare and serious complication of otitis media is a brain abscess. A brain abscess is a pus filled swelling that develops inside the brain.

Symptoms of a brain abscess include:

  • headache
  • changes in mental state, such as confusion or irritability
  • problems with nerve function, such as muscle weakness, slurred speech or paralysis on one side of the body
  • fever
  • seizures (fits)
  • feeling and being sick

A brain abscess is a medical emergency and requires prompt treatment with antibiotics and surgery. The surgeon will usually open the skull and drain the pus from the abscess or remove the abscess entirely.

Read more about the treatment of brain abscesses.

Glossary

Numbness refers to a lack of sensation in a part of the body.

The brain controls thought, memory and emotion. It sends messages to the body controlling movement, speech and senses.

Inflammation is the body's response to infection, irritation or injury, which causes redness, swelling, pain and sometimes a feeling of heat in the affected area.

Content supplied by NHS Choices