Ear Infection
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Ear Infection: Middle Ear, Outer Ear and What Helps
Two different infections in two different places, why most need pain relief rather than antibiotics, and the signs that change the answer entirely.
Key fact: Most ear infections settle within about 3 days, and symptoms can last up to a week. Antibiotics make little difference to most of them, which is why pain relief is the treatment rather than the thing you do while waiting for antibiotics.
Two different infections
"Ear infection" covers two conditions in two different places, with different causes and different treatments. Telling them apart is the first thing that matters, because a treatment that helps one does little for the other.
| Middle ear infection (otitis media) | Outer ear infection (otitis externa) | |
|---|---|---|
| Where | Behind the eardrum | The ear canal itself |
| Typically | Children, often after a cold | Adults, often after water exposure or cotton bud use |
| Pain on touching the ear | No | Yes — pulling the ear or pressing the tragus hurts |
| Itch | Uncommon | Common, often before the pain |
| Discharge | Only if the eardrum perforates | Common — from the canal |
| Main treatment | Pain relief; antibiotics only sometimes | Ear drops — topical treatment, not tablets |
Middle ear or outer ear? goes through the distinction properly, including earwax, which produces some of the same symptoms and none of the infection.
Middle ear infection
Fluid and inflammation build up behind the eardrum, usually after a cold, when the tube connecting the middle ear to the back of the nose stops draining properly. Most are viral, and most settle on their own.
- Commonest in young children, whose drainage tubes are shorter and more horizontal
- Pain is often worse lying down, which is why it announces itself at bedtime
- Muffled hearing is normal while fluid is present, and can persist for weeks afterwards
- Sudden relief of pain with discharge usually means the eardrum has perforated, which normally heals on its own but changes which drops are safe
Outer ear infection
Infection of the skin lining the ear canal — "swimmer's ear". Water softens the skin and washes out the protective wax; cotton buds, earplugs and hearing aids scratch it. Bacteria then take hold.
- Itch first, then pain that becomes disproportionate to how it looks
- Pain on moving the ear — the single most useful sign
- Discharge, and a canal that feels blocked
- Treated with ear drops rather than tablets, because the infection is on the surface of the canal
- Keeping the ear dry is part of the treatment, not an afterthought
Symptoms
In adults
Pain, high temperature, reduced or muffled hearing, discharge, a feeling of pressure or fullness, and itching.
In babies and young children
Rubbing or pulling at the ear, not hearing well, irritability or restlessness, poor feeding, and problems with balance.
Alongside
A cold, sore throat or blocked nose in the days before, particularly with middle ear infection.
Afterwards
Muffled hearing that persists for days or weeks while fluid clears. This is expected and usually resolves.
How long it lasts
The usual course of a middle ear infection is around three days, though it can run to a week. That timescale is the reason antibiotics are held back for most cases — by the time they would begin to work, most infections are already settling.
Treatment
| Approach | What it is for |
|---|---|
| Pain relief — paracetamol or ibuprofen at the right dose, regularly | The mainstay for middle ear infection. Regular dosing for the first 48 hours works considerably better than taking something only when the pain peaks |
| Analgesic ear drops — phenazone with lidocaine, as Otigo | Local pain relief in middle ear infection where the eardrum is intact. Not an antibiotic, and not for use if the eardrum may be perforated |
| Acetic acid 2% spray | Mild outer ear infection, typically for 7 days |
| Antibiotic ear drops, with or without a steroid | More troublesome outer ear infection, typically 7 to 14 days |
| Oral antibiotics | Reserved — see below |
Earache treatment and when antibiotics are needed covers each of these, including how to put drops in so they actually reach the problem.
When antibiotics are used
Most uncomplicated middle ear infections resolve without antibacterial treatment, and a simple painkiller is enough. Antibiotics come into it when:
- The person is systemically very unwell, or there are signs of a more serious illness or complication
- There is a high risk of complications — significant comorbidity, or immunosuppression
- Symptoms are not improving, or are getting worse, after the expected few days
- Very young children with infection in both ears, or where the eardrum has perforated and is discharging
Where an oral antibiotic is needed for a middle ear infection, amoxicillin is the usual first choice in the UK, with clarithromycin or erythromycin where penicillin is unsuitable, typically for 5 to 7 days.
For outer ear infection, oral antibiotics are rarely needed at all — only where the infection is severe, spreading beyond the ear canal, or the person is immunocompromised.
Children
- Middle ear infection is very common in the first few years and usually settles without antibiotics
- Regular pain relief at the correct weight-based dose is the most useful thing a parent can do
- Under 12 months with earache should be seen rather than managed at home
- Analgesic ear drops are used from the age of 1 upwards and are excluded where the eardrum is perforated or discharging
- Persistent muffled hearing after repeated infections may be glue ear, which is assessed rather than treated immediately
- Grommets change which drops are safe, so mention them
When it is urgent
Seek urgent same-day assessment for: swelling, redness or tenderness of the bone behind the ear, or an ear that is being pushed outwards; weakness of one side of the face; severe headache, neck stiffness, confusion or drowsiness; repeated vomiting or severe dizziness; a very high temperature or a child who is clearly unwell; or earache in someone with diabetes or a weakened immune system. Call 999 if there is confusion, a rash that does not fade, difficulty breathing, or a child who is floppy or very hard to rouse.
These are the presentations of mastoiditis, facial nerve involvement and intracranial spread — uncommon, but the reason earache that is getting rapidly worse is not simply waited out. Red flags and prevention covers them in full.
Prevention
- Nothing goes in the ear — no cotton buds, no fingers, no hairgrips. Wax is protective and the canal cleans itself
- Keep water out during an infection, and do not swim
- Dry the ears thoroughly after swimming or showering — tilt and let them drain
- Treat underlying skin conditions, since eczema and psoriasis in the canal predispose to outer ear infection
- Keep up childhood immunisations, which reduce some causes of middle ear infection
- Avoid smoke exposure around children, which increases middle ear infections
Frequently Asked Questions
How long does an ear infection last?
Ear infections often get better on their own within about 3 days, though symptoms can last up to a week. That timescale is why antibiotics are held back for most cases: by the time they would begin to work, most infections are already settling.
Do you need antibiotics for an ear infection?
Usually not. Most uncomplicated middle ear infections resolve without antibacterial treatment, and regular pain relief is the mainstay. Antibiotics are used where someone is systemically very unwell, where there are signs of a more serious illness or complication, where there is a high risk of complications, or where symptoms are not improving or are getting worse.
How do I know if it is an outer or middle ear infection?
Pain when the ear is touched or pulled, or when the small flap in front of the canal is pressed, points to an outer ear infection, and itching often comes first. Middle ear infection usually follows a cold, is not made worse by touching the ear, and is often worse lying down.
Can I use ear drops if my eardrum has burst?
Not without advice. Analgesic ear drops containing phenazone and lidocaine are contraindicated where the eardrum is perforated, and some antibiotic drops are also unsuitable. Sudden relief of pain accompanied by discharge usually means the eardrum has perforated, and treatment needs to be checked rather than assumed.
When should I worry about an ear infection?
Seek urgent assessment for swelling, redness or tenderness of the bone behind the ear, an ear pushed outwards, facial weakness, severe headache, neck stiffness, confusion, repeated vomiting or severe dizziness, a very high temperature, or earache in someone with diabetes or a weakened immune system.
Why does my hearing stay muffled after the infection clears?
Fluid can remain behind the eardrum for days or weeks after the infection itself has settled, and muffled hearing while that clears is expected. Hearing that stays reduced for longer, particularly in a child after repeated infections, should be assessed for glue ear.
References
- NHS. Ear infections. nhs.uk
- National Institute for Health and Care Excellence. Otitis media (acute): antimicrobial prescribing (NG91). nice.org.uk
- National Institute for Health and Care Excellence. Otitis externa: antimicrobial prescribing (NG98). nice.org.uk
- Electronic Medicines Compendium. Otigo 40mg/10mg/g ear drops: Summary of Product Characteristics. medicines.org.uk
- NHS England. Pharmacy First: acute otitis media patient group direction. england.nhs.uk
Medical disclaimer: This article is for informational purposes only and does not constitute medical advice. Ear drops are not interchangeable, and some must never be used if the eardrum may be perforated. A rapidly worsening earache, swelling behind the ear or facial weakness needs urgent assessment. Always consult a qualified healthcare professional for diagnosis and treatment. In a medical emergency, call 999.
