Middle ear infection (otitis media)

Otitis media is an infection of the middle ear that causes inflammation (redness and swelling) and a build-up of fluid behind the eardrum.

Anyone can develop a middle ear infection but infants between six and 15 months old are most commonly affected.

It's estimated that around one in every four children experience at least one middle ear infection by the time they're 10 years old.

Symptoms of a middle ear infection

In most cases, the symptoms of a middle ear infection (otitis media) develop quickly and resolve in a few days. This is known as acute otitis media. The main symptoms include:

• earache
• a high temperature (fever)
• being sick
• a lack of energy
• slight hearing loss - if the middle ear becomes filled with fluid

In some cases, a hole may develop in the eardrum (perforated eardrum) and pus may run out of the ear. The earache, which is caused by the build-up of fluid stretching the eardrum, then resolves.

Signs in young children

As babies are unable to communicate the source of their discomfort, it can be difficult to tell what's wrong with them. Signs that a young child might have an ear infection include:

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

When to seek medical advice

Most cases of otitis media pass within a few days, so there's usually no need to see your GP.

However, see your GP if you or your child have:

• symptoms showing no sign of improvement after two or three days
• a lot of pain
• a discharge of pus or fluid from the ear – some people develop a persistent and painless ear discharge that lasts for many months, known as chronic suppurative otitis media
• an underlying health condition, such as cystic fibrosis or congenital heart disease, which could make complications more likely

Read more about diagnosing middle ear infections

How middle ear infections are treated

Most ear infections clear up within three to five days and don't need any specific treatment. If necessary, paracetamol or ibuprofen should be used to relieve pain and a high temperature.

Make sure any painkillers you give to your child are appropriate for their age. Read more about giving your child painkillers.

Antibiotics aren't routinely used to treat middle ear infections, although they may occasionally be prescribed if symptoms persist or are particularly severe.

Read more about treating middle ear infections

What causes middle ear infections?

Most middle ear infections occur when an infection such as a cold, leads to a build-up of mucus in the middle ear and causes the Eustachian tube (a thin tube that runs from the middle ear to the back of the nose) to become swollen or blocked.

This mean mucus can't drain away properly, making it easier for an infection to spread into the middle ear.

An enlarged adenoid (soft tissue at the back of the throat) can also block the Eustachian tube. The adenoid can be removed if it causes persistent or frequent ear infections. Read more about removing adenoids.

Younger children are particularly vulnerable to middle ear infections as:

• the Eustachian tube is smaller in children than in adults
• a child's adenoids are relatively much larger than an adults

Certain conditions can also increase the risk of middle ear infections, including:

• having a cleft palate – a type of birth defect where a child has a split in the roof of their mouth
• having Down's syndrome – a genetic condition that typically causes some level of learning disability and a characteristic range of physical features

Can middle ear infections be prevented?

It's not possible to prevent middle ear infections, but there are some things you can do that may reduce your child's risk of developing the condition. These include:

• make sure your child is up-to-date with their routine vaccinations – particularly the pneumococcal vaccine and the DTaP/IPV/Hib/HepB (6-in-1) vaccine
• avoid exposing your child to smoky environments (passive smoking)
• don't give your child a dummy once they're older than six to 12 months old
• don't feed your child while they're lying flat on their back
• if possible, feed your baby with breast milk rather than formula milk

Avoiding contact with other children who are unwell may also help reduce your child's chances of catching an infection that could lead to a middle ear infection.

Further problems

Complications of middle ear infections are fairly rare, but can be serious if they do occur.

Most complications are the result of the infection spreading to another part of the ear or head, including:

• the bones behind the ear (mastoiditis)
• the inner ear (labyrinthitis)
• the protective membranes surrounding the brain and spinal cord (meningitis)

Rarely, infections can leave a perforation or hole in the eardrum.

If complications do develop, they often need to be treated immediately with antibiotics in hospital.

Read more about the complications of middle ear infections

A middle ear infection (otitis media) can usually be diagnosed using an instrument called an otoscope.

An otoscope is a small handheld device with a magnifying glass and a light source at the end. Using an otoscope, a doctor can examine the ear to look for signs of fluid in the middle ear, which may indicate an infection.

Signs of fluid in the middle ear can include the ear drum:

• bulging
• being an unusual colour (usually red or yellow)
• having a cloudy appearance

In some cases, a hole may have developed in the eardrum (perforated ear drum) and there may be fluid in the ear canal (the tube between the outer ear and eardrum).

Some otoscopes can also be used to blow a small puff of air into the ear to check for any blockages in the middle ear, which could be a sign of an infection. If the Eustachian tube (the tube that connects the throat and middle ear) is clear, the eardrum will move slightly. If it's blocked, the eardrum will remain still.

Further tests

Further tests are normally only required if treatment isn't working or complications develop. These tests will usually be carried out at your local ear, nose and throat (ENT) department.

Some of the tests that may be carried out are described below.

Tympanometry

Tympanometry is a test that measures how the ear drum reacts to changes in air pressure.

During a tympanometry test, a probe is placed into your child's ear. The probe changes the air pressure at regular intervals while transmitting a sound into the ear. A measuring device is attached to the probe to record how the drum moves and how changes in air pressure affect this movement.

A healthy ear drum should move easily if there's a change in air pressure. If your child's ear drum moves slowly or not at all, it usually suggests there's fluid behind it.

Audiometry

Audiometry is a hearing test that uses a machine called an audiometer to produce sounds of different volume and frequency. This can help determine if your child has any hearing loss as a result of their condition.

During the test, your child listens through headphones and is asked if they can hear the sounds.

Scans

On the very rare occasions where there's a possibility the infection has spread out of the middle ear and into the surrounding area, a scan of the ear may be carried out. This may be either a:

• computerised tomography (CT) scan
• magnetic resonance imaging (MRI) scan

A CT scan takes a series of X-rays and uses a computer to assemble the scans into a more detailed image, whereas an MRI scan uses strong magnetic fields and radio waves to produce images of the inside of the body.

Most middle ear infections (otitis media) clear up within three to five days and don't need any specific treatment.

You can relieve any pain and a high temperature using over the counter painkillers such as paracetamol and ibuprofen.

Make sure any painkillers you give to your child are appropriate for their age.

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

Antibiotics

Antibiotics aren't routinely used to treat middle ear infections as there's no evidence that they speed up the healing process. Many cases are caused by viruses, which antibiotics aren't effective against.

Using antibiotics to treat minor bacterial infections also increases the likelihood of bacteria becoming resistant to them over time. This means more serious infections could become untreatable in the future. Read about antibiotic resistance for more information.

If antibiotics are needed, a five-day course of an antibiotic called amoxicillin is usually prescribed. This is often given as a liquid. Common side effects of amoxicillin include: 

• a rash
• feeling sick
• diarrhoea

An alternative antibiotic such as erythromycin or clarithromycin may be used for people allergic to amoxicillin.

In some cases, your GP may give you a prescription that you can choose to pick up a few days later if the condition hasn't improved by then.

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

Children

Antibiotics are usually only considered if your child:

• has a serious health condition that makes them more vulnerable to complications, such as cystic fibrosis or congenital heart disease
• is less than three months old
• is less than two years old with an infection in both ears
• has discharge coming from their ear

Adults 

Adults may be prescribed antibiotics if:

• they have a serious health condition that makes them more vulnerable to complications, such as cystic fibrosis or congenital heart disease
• symptoms are showing no signs of improvement after four days

Grommets

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

Grommets are inserted under general anaesthetic, which means your child will be asleep and won't feel any pain. The procedure usually only takes about 15 minutes and your child should be able to go home the same day.

A grommet helps keep the eardrum open for several months. As the eardrum starts to heal, the grommet will slowly be pushed out of the eardrum and eventually falls out. This process happens naturally and shouldn't be painful. Most grommets fall out within six to 12 months of being inserted.

Some children need another procedure to replace the grommets if they're still experiencing problems.

Treatment with grommets isn't routinely funded in all areas or for adults with recurrent otitis media.

Serious complications of middle ear infections (otitis media) are very rare but very young children are still at risk because their immune systems are still developing.

Some of the main complications associated with middle ear infections are detailed below.

Mastoiditis

Mastoiditis can develop if an infection spreads out of the middle ear and into the area of bone underneath the ear (the mastoids).

Symptoms of mastoiditis can include:

• a high temperature (fever)
• swelling behind the ear, which pushes it forward 
• redness and tenderness or pain behind the ear
• a creamy discharge from the ear 
• headache
• hearing loss

Mastoiditis is usually treated in hospital with antibiotics given through a drip directly into a vein (intravenously). In some cases, surgery may be required to drain the ear and remove the infected mastoid bone.

Cholesteatoma

A cholesteatoma is an abnormal collection of skin cells inside the ear that can sometimes develop as a result of recurring or persistent middle ear infections.

If it's not treated, a cholesteatoma can eventually damage the delicate structures deep inside your ear, such as the tiny bones that are essential for hearing.

Symptoms of a cholesteatoma can include:

• hearing loss
• weakness in half your face
• dizziness
• tinnitus – hearing sounds from inside their body rather than from an outside source

In most cases, surgery is required to remove a cholesteatoma.

Labyrinthitis

In some cases, an infection in the middle ear can spread into the inner ear and affect the delicate structure deep inside the ear called the labyrinth. This is known as labyrinthitis.

Symptoms of labyrinthitis can include:

• dizziness
• vertigo (the feeling that you, or the environment around you, is moving or spinning)
• loss of balance
• hearing loss

The symptoms of labyrinthitis usually pass within a few weeks, although medication to relieve the symptoms and treat the underlying infection may sometimes be prescribed. Read more about treating labyrinthitis.

Problems with speech and language development

If your child has frequent ear infections that affect their hearing while they're very young, there's a risk their speech and language development may be affected.

Contact your GP for advice if you're concerned about your child's development at any point.

Facial paralysis

In very 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 expressions.

Compression of the nerve can lead to a person being unable to move some or all of their face. This is known as facial paralysis.

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

Meningitis

A very rare and serious complication of a middle ear infection is meningitis. This can occur if the infection spreads to the protective outer layer of the brain and spinal cord (the meninges).

Symptoms of meningitis can include:

• severe headache
• being sick
• a high temperature (fever)
• stiff neck
• sensitivity to light
• rapid breathing
• a blotchy red rash that does not fade or change colour when you place a glass against it (although this is not always present)

If you think your child may have meningitis, call 999 and ask for an ambulance.

Meningitis caused by a bacterial infection is usually treated in hospital with antibiotics given through a drip directly into a vein (intravenously). Read more about treating meningitis.

Brain abscess

Another very rare and serious complication of a middle ear infection is a brain abscess. This is a pus-filled swelling that develops inside the brain.

Symptoms of a brain abscess can include:

• a severe headache
• changes in mental state, such as confusion
• weakness or paralysis on one side of the body
• a high temperature (fever)
• seizures (fits) 

If you suspect that you or someone you know may have a brain abscess, call 999 for an ambulance.

A brain abscess is usually treated using a combination of antibiotics and surgery. The surgeon will usually open the skull and drain the pus from the abscess or remove the abscess entirely.