Introduction

Otitis media is an infection of the middle ear that is particularly common in young children. 

Although anyone can develop a middle ear infection, 75% of cases occur in children under 10. Infants between 6 and 15 months old are most commonly affected.

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

Signs and symptoms of a middle ear infection

Signs that a young child might have an ear infection include:



pulling, tugging, or rubbing their ear



a high temperature (fever)



irritability



poor feeding



restlessness at night



a lack of response to quiet sounds



Older children and adults may have earache, be sick and experience slight hearing loss.

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, you should take your child to see a GP if their symptoms show no sign of improvement after two or three days, they seem to be in a lot of pain, or you notice a discharge of pus or fluid from their ear.

You should also contact your GP if your child has an underlying health condition, such as cystic fibrosis or congenital heart disease, which could make them more vulnerable to complications.

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(appropriate for the child's age) should be used to relieve pain and a high temperature.

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

What causes middle ear infections?

The middle ear is located directly behind the eardrum. It contains three tiny bones that transmit sound vibrations from the eardrum to the hearing organ in the inner ear.

Most middle ear infections occur when a viral or bacterial infection such as a cold causes mucus to build up in the middle ear, which then becomes infected.

Younger children are particularly vulnerable to this type of infection because the tube that allows fresh air into the middle ear (the Eustachian tube) is smaller than it is in adults.

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 (5-in-1) vaccine



avoid exposing your child to smoky environments (passive smoking)



don't give your child a dummy once they are older than 6 to 12 months old



don't feed your child while they are 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), or the protective membranes surrounding the brain and spinal cord (meningitis).

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

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Glue ear

In some cases, the middle ear can become filled with fluid for long periods, causing hearing difficulties. This is known as otitis media with effusion, or "glue ear".

Symptoms of 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 of acute otitis media include:



earache



a high temperature (fever)



being sick



a lack of energy



slight hearing loss



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.

Although it's less common than acute otitis media, some children have a persistent and painless discharge from their ear that lasts for many months as a result of an ear infection. This is known as chronic suppurative otitis media (CSOM). 

Symptoms in babies

As babies are unable to communicate the source of their discomfort, it can be difficult to tell what is wrong with them. Signs your baby may have an ear infection 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 inattentiveness



loss of balance



 

When to seek medical advice

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

However, you should take your child to see a GP if their symptoms show no sign of improvement after two or three days, they seem to be in a lot of pain, or you notice a discharge of pus or fluid from their ear.

You should also contact your GP if your child has an underlying health condition, such as cystic fibrosis or congenital heart disease, which could make them more vulnerable to complications.

Causes of middle ear infections 

Most middle ear infections (otitis media) are caused by a viral or bacterial infection spreading into the middle ear.

They often occur when an infection, such as a cold, leads to a build-up of mucus in the middle ear and causes part of the ear called the Eustachian tube to become swollen or blocked.

The Eustachian tube is a thin tube that runs from the middle ear to the back of the nose. Its main functions are to help maintain normal air pressure within the ear and to help drain away mucus and other debris from the middle ear.

If the tube becomes swollen or blocked, mucus can't drain away properly, which makes 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, which can cause a build-up of mucus and lead to a middle ear infection. The adenoid can be removed if it causes persistent or frequent ear infections.

Who's most at risk?

As a child's Eustachian tubes are smaller than an adult's, they are more likely to become blocked and infected. A child's adenoids are also much larger than an adult's in relative terms.

These are the main reasons why more than 75% of middle ear infections occur in children younger than 10, with most cases affecting infants between 6 and 15 months old.

Other factors that can increase the risk of developing a middle ear infection include:



attending a nursery or day care centre – this increases the chances of a child being exposed to infections from other children



being exposed to tobacco smoke (passive smoking)



being fed formula milk, rather than breast milk



having a family history of middle ear infections



feeding your child while they are lying flat on their back



using a dummy



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



Diagnosing middle ear infection 

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

An otoscope is a small handheld device that has a magnifying glass and a light source at the end. It is used to examine the ear. Using an otoscope, a doctor can detect certain signs that indicate fluid in the middle ear, which in turn 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) or 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 is blocked, the eardrum will remain still.

Further tests

Further tests are normally only required if treatment is not 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. A healthy ear drum should move easily if there is a change in air pressure. If your child's ear drum moves slowly or not at all, it usually suggests that there is fluid behind it.

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.

If the movement of the eardrum is restricted, it usually indicates that there is fluid in the middle ear.

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 to the sounds through headphones and they are asked to say when they can hear a sound and when they cannot.

Scans

On the very rare occasions where there is a possibility the infection has spread out of the middle ear and into the surrounding area, acomputerised tomography (CT) scan or a magnetic resonance imaging (MRI) scan may be carried out.

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.

 

Treating middle ear infection 

Most middle ear infections (otitis media) will clear up within three 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. However, 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 until the condition passes.

Antibiotics

The routine use of antibiotics to treat middle ear infections is not recommended as there is no evidence that they speed up the healing process. Many cases are caused by viruses, which antibiotics are ineffective 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.

Antibiotics are therefore usually only considered if:

If antibiotics are needed, a five-day course of an antibiotic called amoxicillin is usually prescribed. This is often given as a liquid suspension that your child has to drink. Common side effects of amoxicillin include a rash, feeling sick and diarrhoea.

If your child is allergic to amoxicillin, an alternative antibiotic such as erythromycin may be used.

In some cases, your GP may give you a prescription that you can choose to pick up a few days later if your child's 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.

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 will help keep the eardrum open for several months. As the eardrum starts to heal, the grommet will slowly be pushed out of the eardrum and will eventually fall out. This process happens naturally and should not be painful. Most grommets will fall out within 6 to 12 months of being inserted.

Some children will need another procedure to replace the grommets if they are still experiencing problems.



your child has a serious health condition that makes them more vulnerable to complications, such as cystic fibrosis or congenital heart disease



your child is less than three months old, or they are less than two years old and have an infection in both ears



your child's symptoms are severe



your child has discharge coming from their ear



your child's symptoms show no signs of improvement after four days



 

Complications of middle ear infection 

Serious complications of middle ear infections (otitis media) are much rarer now than they were in the past.

However, very young children are still at risk of developing complications 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:

Mastoiditis is usually treated in hospital with antibiotics given through a drip directly into a vein. 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 is 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:

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:

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.

Problems with speech and language development

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

Contact your GP for advice if you are 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 ismeningitis. This can occur if the infection spreads to the protective outer layer of the brain and spinal chord (the meninges).

Symptoms of meningitis can include:

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.

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:

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.



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



hearing loss



weakness in half your face



dizziness



tinnitus (hearing sounds from inside their body rather than from an outside source)



dizziness



vertigo (the feeling that you, or the environment around you, is moving or spinning)



loss of balance



hearing loss



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)



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) 





Ear infection, inner