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Ear infection (middle ear)

Definition

An ear infection (acute otitis media) is most often a bacterial or viral infection that affects the middle ear, the air-filled space behind the eardrum that contains the tiny vibrating bones of the ear. Children are more likely than adults to get ear infections.

Ear infections frequently are painful because of inflammation and buildup of fluids in the middle ear.

Because ear infections often clear up on their own, treatment may begin with managing pain and monitoring the problem. Ear infection in infants and severe cases in general often require antibiotic medications. Long-term problems related to ear infections persistent fluids in the middle ear, persistent infections or frequent infections can cause hearing problems and other serious complications.

Symptoms

The onset of signs and symptoms of ear infection is usually rapid.

Children
Signs and symptoms common in children include:

  • Ear pain, especially when lying down
  • Tugging or pulling at an ear
  • Difficulty sleeping
  • Crying more than usual
  • Acting more irritable than usual
  • Difficulty hearing or responding to sounds
  • Loss of balance
  • Fever of 100 F (38 C) or higher
  • Drainage of fluid from the ear
  • Headache
  • Loss of appetite

Adults
Common signs and symptoms in adults include:

  • Ear pain
  • Drainage of fluid from the ear
  • Diminished hearing

When to see a doctor
Signs and symptoms of an ear infection can indicate a number of conditions. It's important to get an accurate diagnosis and prompt treatment. Call your child's doctor if:

  • Symptoms last for more than a day
  • Ear pain is severe
  • Your infant or toddler is sleepless or irritable after a cold or other upper respiratory infection
  • You observe a discharge of fluid, pus or bloody discharge from the ear

An adult with ear pain or discharge should see a doctor as soon as possible.

Causes

An ear infection is caused by a bacterium or virus in the middle ear. This infection often results from another illness cold, flu or allergy that causes congestion and swelling of the nasal passages, throat and eustachian tubes.

Role of eustachian tubes
The eustachian tubes are a pair of narrow tubes that run from each middle ear to high in the back of the throat, behind the nasal passages. The throat end of the tubes open and close to:

  • Regulate air pressure in the middle ear
  • Refresh air in the ear
  • Drain normal secretions from the middle ear

Swelling, inflammation and mucus in the eustachian tubes from an upper respiratory infection or allergy can block them, causing the accumulation of fluids in the middle ear. A bacterial or viral infection of this fluid is usually what produces the symptoms of an ear infection.

Ear infections are more common in children, in part, because their eustachian tubes are narrower and more horizontal factors that make them more difficult to drain and more likely to get clogged.

Role of adenoids
Adenoids are two small pads of tissues high in the back of the nose believed to play a role in immune system activity. This function may make them particularly vulnerable to infection and inflammation.

Because adenoids are near the opening of the eustachian tubes, inflammation or enlargement of the adenoids may block the tubes, thereby contributing to middle ear infection. Inflammation of adenoids is more likely to play a role in ear infections in children because children have more active and relatively larger adenoids.

Related conditions
Conditions of the middle ear that may be related to an ear infection or result in similar middle ear problems include the following:

  • Otitis media with effusion is inflammation and fluid buildup (effusion) in the middle ear without bacterial or viral infection. This may occur because the fluid buildup persists after an ear infection has resolved. It may also occur because of some dysfunction or noninfectious blockage of the eustachian tubes.
  • Chronic suppurative otitis media is a persistent ear infection that results in tearing or perforation of the eardrum.

Middle ear

Illustration showing inside of your ear
Enlarge Image
The middle ear includes three small bones the hammer, anvil and stirrup. The middle ear is separated from your external ear by the eardrum and connected to the back of your nose and throat by ...

Risk factors

Risk factors for ear infections include:

  • Age. Children between the ages of 6 months and 2 years are more susceptible to ear infections because of the size and shape of the eustachian tubes and because of their poorly developed immune systems.
  • Group child care. Children cared for in group settings are more likely to get colds and ear infections than are children who stay home because they're exposed to more infections, such as the common cold.
  • Infant feeding. Babies who drink from a bottle, especially while lying down, tend to have more ear infections than do babies who are breast-fed.
  • Seasonal factors. Ear infections are most common during the fall and winter when colds and flu are prevalent. People with seasonal allergies may have a greater risk of ear infections during seasonal high pollen counts.
  • Poor air quality. Exposure to tobacco smoke or high levels of air pollution can increase the risk of ear infection.

Complications

Most ear infections don't cause long-term complications. Frequent or persistent infections and persistent fluid buildup can result in some serious complications:

  • Impaired hearing. Mild hearing loss that comes and goes is fairly common with an ear infection, but it usually returns to what it was before the infection after the infection clears. Persistent infection or persistent fluids in the middle ear may result in more significant hearing loss. If there is some permanent damage to the eardrum or other middle ear structures, permanent hearing loss may occur.
  • Speech or developmental delays. If hearing is temporarily or permanently impaired in infants and toddlers, they may experience delays in speech, social and developmental skills.
  • Spread of infection. Untreated infections or infections that don't respond well to treatment can spread to nearby tissues. Infection of the mastoid, the bony protrusion behind the ear, is called mastoiditis. This infection can result in damage to the bone and the formation of pus-filled cysts. Rarely, serious middle ear infections spread to other tissues in the skull, including the brain.
  • Tearing of the eardrum. Most eardrum tears heal within 72 hours. In some cases, surgical repair is needed.

Preparing for your appointment

You'll likely begin by seeing your family doctor or your child's pediatrician. You may be referred to a specialist in ear, nose and throat (ENT) disorders (otolaryngologist) if the problem has persisted for some time, is not responding to treatment or has occurred frequently.

If your child is old enough to respond, before your appointment talk to the child about questions the doctor may ask and be prepared to answer questions on behalf of your child. Questions for adults will address most of the same issues.

  • What signs or symptoms have you observed?
  • When did the symptoms begin?
  • Is there ear pain? How would you describe the pain mild, moderate or severe?
  • Have you observed possible signs of pain in your infant or toddler, such as ear pulling, difficulty sleeping or unusual irritability?
  • Has your child had a fever?
  • Has there been any discharge from the ear? Is the discharge clear, cloudy or bloody?
  • Have you observed any hearing impairment? Does your child respond to quiet sounds? Does your older child ask "What?" frequently?
  • Has your child recently had a cold, flu or other respiratory symptoms?
  • Does your child have seasonal allergies?
  • Has your child had an ear infection in the past? When?
  • Is your child allergic to any medication, such as penicillin?

Tests and diagnosis

Your doctor can usually diagnose an ear infection or another condition based on the symptoms you describe and an office exam. The doctor will likely use a lighted instrument (an otoscope) to look at the ears, throat and nasal passage. He or she will also listen to your child breathe with a stethoscope.

Pneumatic otoscope
An instrument called a pneumatic otoscope is often the only specialized tool a doctor needs to make a diagnosis of an ear infection. This instrument enables the doctor to look in the ear and judge how much fluid may be behind the eardrum. With the pneumatic otoscope, the doctor gently puffs air against the eardrum. Normally, this puff of air would cause the eardrum to move. If the middle ear is filled with fluid, your doctor will observe little to no movement of the eardrum.

Additional tests
Your doctor may perform other diagnostic tests if there is any doubt about a diagnosis, if the condition hasn't responded to previous treatments, or if there are other persistent or serious problems.

  • Tympanometry. This test measures the movement of the eardrum. The device, which seals off the ear canal, adjusts air pressure in the canal, thereby causing the eardrum to move. The device quantifies how well the eardrum moves and provides an indirect measure of pressure within the middle ear.
  • Acoustic reflectometry. This test measures how much sound emitted from a device is reflected back from the eardrum an indirect measure of fluids in the middle ear. Normally, the eardrum absorbs most of the sound. However, the more pressure there is from fluid in the middle ear, the more sound the eardrum will reflect.
  • Tympanocentesis. Rarely, a doctor may use a tiny tube that pierces the eardrum to drain fluid from the middle ear a procedure called tympanocentesis. Tests to determine the infectious agent in the fluid may be beneficial if an infection hasn't responded well to previous treatments.
  • Other tests. If your child has had persistent ear infections or persistent fluid buildup in the middle ear, your doctor may refer you to a hearing specialist (audiologist), speech therapist or developmental therapist for tests of hearing, speech skills, language comprehension or developmental abilities.

What a diagnosis means

  • Acute otitis media. The diagnosis of "ear infection" is generally shorthand for acute otitis media. Your doctor likely makes this diagnosis if he or she observes signs of fluid in the middle ear, if there are signs or symptoms of an infection, and if the onset of symptoms was relatively sudden.
  • Otitis media with effusion. If the diagnosis is otitis media with effusion, the doctor has found evidence of fluid in the middle ear, but there are presently no signs or symptoms of infection.
  • Chronic suppurative otitis media. If the doctor makes a diagnosis of chronic suppurative otitis media, he or she has found that a persistent ear infection resulted in tearing or perforation of the eardrum.

Treatments and drugs

Most ear infections resolve without treatment with antibiotics. What's best for your child depends on many factors, including your child's age and the severity of symptoms.

A wait-and-see approach
Symptoms of ear infections usually improve within the first couple of days, and most infections clear up on their own within one to two weeks without any treatment. The American Academy of Pediatrics and the American Academy of Family Physicians recommend a wait-and-see approach as one option for:

  • Children 6 to 23 months with mild inner ear pain in one ear for less than 48 hours and a temperature less than 102.2 F (39 C)
  • Children 24 months and older with mild inner ear pain in one or both ears for less than 48 hours and a temperature less than102.2 F (39 C)

Some evidence suggests that treatment with antibiotics might be beneficial for certain children with ear infections. Talk to your doctor about the benefits of antibiotics weighed against the potential side effects and concern about overuse of antibiotics creating strains of resistant disease.

Managing pain
Your doctor will advise you on treatments to lessen pain from an ear infection. These may include the following:

  • A warm compress. Placing a warm, moist washcloth over the affected ear may lessen pain.
  • Pain medication. Your doctor may advise the use of over-the-counter acetaminophen (Tylenol, others) or ibuprofen (Motrin IB, Advil, others) to relieve pain. Use the drugs as directed on the label. Use caution when giving aspirin to children or teenagers. Because aspirin has been linked with Reye's syndrome, use caution when giving aspirin to children or teenagers. Although aspirin is approved for use in children older than age 2, children and teenagers recovering from chickenpox or flu-like symptoms should never take aspirin. Talk to your doctor if you have concerns.
  • Eardrops. Prescription eardrops, such as antipyrine-benzocaine-glycerin (Aurodex), may provide additional pain relief for those whose ear drums are intact (not torn or perforated). To administer drops to your child, warm the bottle by placing it in warm water. Put the recommended dose in your child's ear while he or she lies on a flat surface with the infected ear facing up. Benzocaine has been linked to a rare but serious, sometimes deadly, condition that decreases the amount of oxygen that the blood can carry. Don't use benzocaine in children younger than age 2 without supervision from a health care professional, as this age group has been the most affected. If you're an adult, never use more than the recommended dose of benzocaine and consider talking with your doctor.

Antibiotic therapy
Your doctor may recommend antibiotic treatment for an ear infection in the following situations:

  • Children 6 months and older with moderate to severe ear pain in one or both ears for at least 48 hours or a temperature of 102.2 F (39 C) or higher
  • Children 6 to 23 months with mild inner ear pain in one or both ears for less than 48 hours and a temperature less than 102.2 F (39 C)
  • Children 24 months and older with mild inner ear pain in one or both ears for less than 48 hours and a temperature less than 102.2 F (39 C)

Even after symptoms have improved, be sure to use all of the antibiotic as directed. Failing to do so can result in recurring infection and resistance of bacteria to antibiotic medications. Talk to your doctor or pharmacist about what to do if you accidentally skip a dose.

Ear tubes
If your child has recurrent otitis media three episodes in six months or four episodes in a year with at least one occurring in the past six months or otitis media with effusion persistent fluid buildup in the ear after an infection has cleared up or in the absence of any infection your doctor may recommend a procedure to drain fluid from the middle ear.

During an outpatient surgical procedure called a myringotomy, a surgeon creates a tiny hole in the eardrum that enables him or her to suction fluids out of the middle ear. A tiny tube (tympanostomy tube) is placed in the opening to help ventilate the middle ear and prevent the accumulation of more fluids. Some tubes are intended to stay in place for six months to a year and then fall out on their own. Other tubes are designed to stay in longer and may need to be surgically removed.

The eardrum usually closes up again after the tube falls out or is removed.

Treatment for chronic suppurative otitis media
Chronic infection that results in perforation of the eardrum chronic suppurative otitis media is difficult to treat. It's often treated with antibiotics administered as drops. You'll receive instructions on how to suction fluids out through the ear canal before administering drops.

Monitoring
Children with frequent or persistent infections or with persistent fluid in the middle ear will need to be monitored closely. Talk to your doctor about how often you should schedule follow-up appointments. Your doctor may recommend regular hearing and language tests.

Prevention

The following tips may reduce the risk of developing ear infections:

  • Prevent common colds and other illnesses. Teach your children to wash their hands frequently and thoroughly and to not share eating and drinking utensils. Teach your children to cough or sneeze into their arm crook. If possible, limit the time your child spends in group child care. A child care setting with fewer children may help. Try to keep your child home from child care or school when ill.
  • Avoid secondhand smoke. Make sure that no one smokes in your home. Away from home, stay in smoke-free environments.
  • Breast-feed your baby. If possible, breast-feed your baby for at least six months. Breast milk contains antibodies that may offer protection from ear infections.
  • If you bottle-feed, hold your baby in an upright position. Avoid propping a bottle in your baby's mouth while he or she is lying down. Don't put bottles in the crib with your baby.
  • Talk to your doctor about vaccinations. Ask your doctor about what vaccinations are appropriate for your child. Seasonal flu shots and pneumococcal vaccines may help prevent ear infections.
Updated: 4/20/2013

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