Middle Ear Infection (Otitis Media): Symptoms, Causes & Treatment

Ear infections (acute otitis media) occur when a virus or bacteria infects the space behind your child’s eardrum. Symptoms include ear pain that may cause your infant or toddler to be especially fussy or irritable. Often, ear infections clear on their own. Sometimes, children need antibiotics, pain-relieving medications or ear tubes.

Overview

What is an ear infection (acute otitis media)?

An ear infection, also called acute otitis media, is a sudden infection in your middle ear. The middle ear is the air-filled space between your eardrum and inner ear. It houses the delicate bones that transmit sound vibrations from your eardrum to your inner ear so you can hear.

Eustachian tubes are canals that connect your middle ear to the back of your throat. They regulate air pressure in your ear and prevent fluid from accumulating in your middle ear space.

If a eustachian tube doesn’t function well, fluid has a hard time draining from your middle ear space and can cause muffled hearing. Ear infections (from viruses and bacteria) also cause middle ear fluid. In these cases, the middle ear fluid is infected and often causes discomfort in addition to muffled hearing.

Viruses and bacteria can infect undrained fluid inside your middle ear, causing an ear infection.

How common are ear infections?

Middle ear infections are the most common childhood illness other than colds. Ear infections occur most often in children between 6 months and 2 years. They’re common until age 8.

Older children and adults can get ear infections, too, but they don’t happen nearly as often as in young children.

Why are children more likely to get ear infections than adults?

Children get ear infections more often than adults because:

Their eustachian tubes don’t function as well as adults, and this encourages fluid to gather behind the eardrum.
Their immune system, the body’s infection-fighting system, is still developing.
They’re more likely to catch illnesses from other children.

Symptoms and Causes

What are the symptoms of an ear infection?

Symptoms of an ear infection often begin after a cold. They include:

Ear pain.
Loss of appetite.
Trouble sleeping.
Trouble hearing in the ear that’s blocked.
A feeling of fullness or pressure in your ear.
Yellow, brown or white drainage from your ear. (This may mean that your eardrum has broken.)

Don’t place anything in your ear canal if you have drainage from your ear. An item touching a torn (ruptured) eardrum can cause more damage.

Infants and children

Since small children and infants can’t always communicate their symptoms, it’s important to recognize the signs. A child with an ear infection may:

Rub or tug on their ears.
Cry more than usual or act fussy.
Have a fever ranging from 100.5 to 104 degrees Fahrenheit (38 to 40 degrees Celsius). (Half of children have fevers with ear infections.)
Start mouth breathing or have increased snoring. Mouth breathing may be a sign of enlarged adenoids. (Adenoids are small pads of tissue above your throat, behind your nose and near your eustachian tubes.) Adenoids may become infected/inflamed with the same viruses or bacteria that cause ear infections.
Refuse to eat during feedings. (Pressure in the middle ear changes as your child swallows, causing more pain and less desire to eat.)

What causes an ear infection?

Bacteria and viruses cause ear infections. Often, ear infections begin after a cold or another upper respiratory infection. The germs travel into your middle ear through the eustachian tube. Once inside, the virus or bacteria can cause your eustachian tubes to swell. The swelling can cause the tube to become blocked, leading to poor eustachian tube function and infected fluid in your middle ear.

Are ear infections contagious?

Ear infections aren’t contagious, but the virus and/or bacteria causing the infection are. Multiple types of bacteria and viruses cause ear infections, including ones that cause colds and the flu.

What are the risk factors for ear infections?

Risk factors for ear infections include:

Age: Infants and young children (between 6 months and 2 years) are at a greater risk for ear infections.
Family history: Getting ear infections can run in the family.
Colds: Having a cold increases your risk of developing an ear infection. Children in daycare and group settings are at a greater risk of ear infections because they’re more likely to be around children with colds or other contagious respiratory illnesses
Chronic illnesses: Long-term illnesses, including immune deficiency and chronic respiratory diseases (such as cystic fibrosis and asthma), can increase your risk of ear infections.
Ethnicity: Children who are Native American, Hispanic and Alaska Natives have more ear infections than children of other ethnic groups.
Poor air quality and smoky environments: Air pollution and exposure to secondhand smoke increase your risk of getting an ear infection.

What are the complications of ear infections?

Most ear infections don’t cause long-term issues. When complications happen, they’re usually related to repeated or ongoing ear infections. Complications include:

Hearing loss: Temporary hearing loss or changes in your hearing (muffling or sound distortions) are common during an ear infection. Repeated or ongoing infections or damage to internal structures in your ear can cause more significant hearing loss.
Delayed speech and language development: Children need to hear to learn language and develop speech. Muffled hearing or hearing loss for any length of time can significantly delay development.
Torn eardrum: About 5% to 10% of children with an ear infection develop a small tear in their eardrum. Often, the tear heals on its own. If it doesn’t, your child may need surgery.
Spread of the infection: Untreated infections or infections that don’t improve on their own can spread. Infection can spread to the bone behind your ear (mastoiditis). Occasionally, an infection can spread to the membranes surrounding your brain and spinal cord (meninges) and cause meningitis.

Diagnosis and Tests

How is an ear infection diagnosed?

Most healthcare providers can tell if your child has an ear infection based on their symptoms, a physical exam to check for signs of a cold and an ear exam. For the ear exam, your child’s healthcare provider will view your child’s eardrum using a lighted instrument called an otoscope. An inflamed, swollen or red eardrum is a sign of an ear infection.

Your child’s provider may use a pneumatic otoscope to check for fluid in your child’s middle ear. A pneumatic otoscope blows a puff of air at the eardrum, which should cause it to move back and forth. It won’t move easily if there’s fluid inside your child’s ear.

Are there additional tests my child may need?

Your child may need other tests, including:

Tympanometry: This test uses air pressure to check for fluid in your child’s middle ear.
Acoustic reflectometry: This test uses sound waves to check for fluid in your child’s middle ear.
Tympanocentesis: This procedure allows your child’s provider to remove fluid from your child’s middle ear and test it for viruses and bacteria. Their provider may recommend tympanocentesis if other treatments haven’t cleared the infection.
Hearing tests: A provider called an audiologist might perform hearing tests to determine if your child has hearing loss. Hearing loss is more common in children with long-lasting or frequent ear infections or fluid in the middle ear that doesn’t drain.

Management and Treatment

How is an ear infection treated?

Treatment depends on many factors, including:

Your child’s age.
The severity of the infection.
The nature of the infection (first-time, ongoing or repeat infection).
Whether fluid remains in the middle ear for a long time.

Often, ear infections heal without treatment. Your provider may monitor your child’s condition to see if it improves before prescribing treatments. Your child may need antibiotics or surgery for infections that don’t go away. In the meantime, pain medicines can help with symptoms like ear pain.

Antibiotics

Your child may need antibiotics if bacteria are causing the ear infection. Healthcare providers may wait up to three days before prescribing antibiotics to see if a mild infection clears on its own. If an infection is severe, your child may need to start antibiotics immediately.

The American Academy of Pediatrics provides guidelines on when a child should receive antibiotics and when it’s better to observe. Factors include your child’s age, the severity of their infection and their temperature. The table below summarizes the recommendations.

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 degrees F (39 degrees C) or higher.	Treat with antibiotics.
6 months through 23 months; in both ears.	Mild for less than 48 hours and temp less than 102.2 degrees F (39 degrees C).	Treat with antibiotics.
6 months to 23 months; in one ear.	Mild for less than 48 hours and temp less than 102.2 degrees F (39 degrees C).	Treat with antibiotics OR observe. If observe, start antibiotics if the child’s condition 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 less than 48 hours and temp less than 102.2 degrees F (39 degrees C).	Treat with antibiotics OR observe. If observe, start antibiotics if the child’s condition worsens or doesn’t improve within 48 to 72 hours of start of symptoms.

Even if symptoms improve, don’t stop taking the medicine until your provider tells you to stop. The infection can return if your child doesn’t take all antibiotics as prescribed.

Pain-relieving medications

Your healthcare provider may recommend over-the-counter (OTC) medicines, such as acetaminophen (Tylenol) or ibuprofen (Advil, Motrin), to relieve pain and reduce fever. They may prescribe pain-relieving ear drops. Follow your provider’s instructions about what medicines are safe for your child.

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

Ear tubes (tympanostomy tubes)

Your child may need ear tubes if they experience frequent ear infections, infections that don’t improve with antibiotics or hearing loss related to fluid buildup. An ear, nose and throat (ENT) specialist places the tubes during a tympanostomy. It’s a short (approximately 10-minute) procedure. Your child can go home that same day.

During a tympanostomy, a provider inserts a small metal or plastic tube into a tiny incision (cut) in your child’s eardrum. The procedure to perforate (pierce a hole into) and drain the eardrum is called a myringotomy. Once the tubes are in place, they let air into the middle ear and allow fluid to drain.

The tube usually stays in place for 12 to 18 months. It may fall out on its own, or your child may need surgery to remove it. Once the tubes are gone, the hole in your child’s eardrum will heal and close.

Prevention

What can I do to prevent ear infections?

Here are some ways to reduce your or your child’s risk of ear infections:

Prevent colds and other respiratory illnesses. Be proactive in preventing colds, especially during your child’s first year. Teach them about frequent handwashing and coughing or sneezing into their elbow. Don’t allow them to share food, cups or utensils. If it’s an option, avoid large daycare centers until they’re older.
Avoid secondhand smoke. Avoid exposure to secondhand smoke, and don’t allow others to smoke around your child.
Breastfeed (chestfeed) your baby. If possible, breastfeed your baby during the first six to 12 months. Antibodies in breast milk (chest milk) fight viruses and bacteria that cause infections.
Bottle-feed your baby in an upright position. If you bottle-feed, hold your baby upright so their head is higher than their stomach. This position can prevent formula or other fluids from flowing backward and collecting in their eustachian tubes.
Stay up to date on vaccinations. Ensure your child’s immunizations are current, including yearly flu shots for children 6 months and older. Ask your child’s pediatrician about vaccines for pneumococcal disease and meningitis.

Outlook / Prognosis

Can an ear infection go away on its own?

Yes, most infections go away on their own. This is why your healthcare provider may wait before prescribing medications like antibiotics. In the meantime, pain relievers can help with symptoms like ear pain.

Depending on your child’s age, symptoms and temperature, they may need antibiotics to heal. If your child has ongoing or frequent infections, or if fluid remains in the middle ear and puts their hearing at risk, your child may need ear tubes. Follow your healthcare provider’s guidance about caring for your child.

When can my child return to normal daily activities?

Children can return to school or daycare when their fever is gone.

Living With

When should I see my healthcare provider about an ear infection?

Call your healthcare provider immediately if:

- - - Your child develops a stiff neck.
    - Your child acts sluggish, looks or acts very sick, or doesn’t stop crying despite all efforts.
    - Your child’s walk isn’t steady.
    - Your or your child’s ear pain is severe.
    - Your or your child has a fever over 104 degrees F (40 degrees C).
    - Your child shows 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:

- - - A fever remains or comes back more than 48 hours after starting an antibiotic.
    - Ear pain isn’t better after three days of taking an antibiotic.

Additional Common Questions

Do I need to cover my child’s ears if they go outside with an ear infection?

No, you don’t need to cover their ears to go outside.

Can my child go swimming with an ear infection?

Swimming is OK as long as your child doesn’t have a tear (perforation) in their eardrum or drainage from their 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 you may feel temporary pain during takeoff and landing when flying. Swallowing fluids or chewing gum during descent can help with the pain. If your small child has an ear infection, have them suck on a pacifier to relieve discomfort during air travel.

A note from Cleveland Clinic

Contact your child’s pediatrician if they show signs of an ear infection and their condition doesn’t improve within two to three days. Often, ear infections get better without treatment. Depending on your child’s age and symptoms, they may need antibiotics. Your child’s healthcare provider can recommend pain relievers for your child as their body works through the illness.

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