Earache: Treatment and When Antibiotics Are Needed
Why regular pain relief is the treatment rather than the wait, where analgesic ear drops fit, and how to put drops in so they actually reach the problem.
Part of the Complete Ear Infection Guide.
Key fact: For a middle ear infection, regular pain relief is the treatment, not the waiting room. Paracetamol or ibuprofen given on the clock for the first 48 hours — rather than only when the pain peaks — does more for most people than an antibiotic would.
Pain relief first, and properly
Most uncomplicated middle ear infections settle in about three days without antibacterial treatment, and a simple analgesic is what is actually recommended. The detail that matters is how it is taken.
- Regularly, on the clock, for the first 48 hours — not only when the pain becomes unbearable. Chasing pain always works less well than staying ahead of it
- At the correct dose for age and weight in children, which is where under-dosing is common
- Paracetamol or ibuprofen; either is reasonable, and they can be alternated if one alone is not enough and both are suitable
- Something warm against the ear helps some people, and does no harm
- Sleeping propped up reduces the pressure that makes middle ear pain worse lying flat
Analgesic ear drops
Otigo contains phenazone and lidocaine and is licensed for local symptomatic relief of pain in middle ear conditions without perforation of the eardrum. It is a painkiller applied locally, not an antibiotic.
| Detail | |
|---|---|
| Dose | 4 drops into the affected ear canal, two or three times daily |
| Maximum duration | 7 days. If symptoms have not improved within 7 days, or worsen at any point, treatment should be reviewed |
| Age | Used from 1 year upwards under the Pharmacy First criteria; no dose adjustment by age, as the effect is local |
| Absolute contraindication | Perforated eardrum, whether from infection or injury, including after grommet surgery |
Stop and seek advice if discharge develops while using these drops — that may mean the eardrum has perforated. With a perforation, the drops can reach middle ear structures and cause harm there. This is also why they are not used where the eardrum cannot be seen or its condition is unknown.
Used appropriately, these drops sit neatly inside current guidance: they treat the symptom that actually needs treating, and they can avoid an antibiotic being prescribed for an infection that was going to settle anyway.
Treating an outer ear infection
Outer ear infection is treated topically. The infection is on the skin of the canal, which oral antibiotics reach poorly.
| Severity | Usual approach | Duration |
|---|---|---|
| Mild | Acetic acid 2% spray, which restores the canal's natural acidity, plus a simple painkiller | About 7 days |
| More troublesome | A topical antibiotic, with or without a corticosteroid to reduce swelling | 7 to 14 days |
| Not settling | Consider fungal infection, treated with a topical antifungal such as clotrimazole solution | As directed |
| Severe, spreading, or immunocompromised | Oral antibiotics and assessment | As directed |
- Keeping the ear dry is part of the treatment — no swimming, and keep water out when showering
- Nothing goes in the ear, including cotton buds, while it settles
- Remove earplugs and pause hearing aid use where possible, since both keep the canal moist and occluded
- A swollen canal may need a wick inserted by a clinician so drops can get past the swelling
Putting drops in properly
Most "the drops did not work" stories are actually "the drops never reached the problem".
| Step | What it involves |
|---|---|
| Warm the bottle | In your hand for a minute. Cold drops in the ear cause dizziness |
| Lie on your side | Affected ear uppermost |
| Straighten the canal | Pull the ear gently up and back in an adult, down and back in a young child |
| Put the drops in | The full number stated, aimed at the canal wall rather than straight down |
| Stay lying down | For 3 to 5 minutes, so the drops run in rather than out |
| Press the tragus gently | A few times, to pump the drops along the canal |
When antibiotics are needed
For a middle ear infection, antibiotics are considered when:
- The person is systemically very unwell
- There are symptoms or signs of a more serious illness or complication
- There is a high risk of complications — significant comorbidity, or a weakened immune system
- Symptoms are not improving, or are worsening, after the expected few days
- A very young child has infection in both ears, or the eardrum has perforated and is discharging
A back-up prescription is a middle path worth asking about: an antibiotic to collect only if things have not improved after a couple of days. It avoids both an unnecessary course and a second appointment.
For an outer ear infection, oral antibiotics are rarely needed — only for severe infection, spread beyond the canal, or immunocompromise.
Which antibiotic
- Amoxicillin is the usual first choice for middle ear infection in the UK, typically for 5 to 7 days
- Clarithromycin or erythromycin where penicillin is unsuitable, with erythromycin generally used in pregnancy
- Finish the course as prescribed
- Antibiotic ear drops do nothing for a middle ear infection with an intact eardrum — they cannot get through it. They are for the canal
What does not help
- Decongestants and antihistamines — no good evidence of benefit in acute middle ear infection
- Olive oil or warm oil during an active infection — softening drops are for wax, not infection, and are unsafe with a perforation
- Ear candles — ineffective, and they cause burns and canal damage
- Cotton buds — the cause of many outer ear infections rather than a treatment
- Antibiotics for most middle ear infections — little difference to an illness that mostly settles in three days
- Swimming through it — keeping the ear dry genuinely matters for outer ear infection
If it is not improving
| Possibility | What to do |
|---|---|
| Wrong part of the ear | Oral antibiotics for a canal infection, or drops for a middle ear infection, will both disappoint. See middle ear or outer ear? |
| Drops not reaching | Technique, or a canal too swollen to admit them — a wick may be needed |
| Fungal infection | Consider where an outer ear infection has not responded to antibacterial drops |
| Referred pain | Teeth, jaw joint or throat, with a normal ear |
| It is getting worse rather than static | Stop waiting and get assessed — see red flags |
Frequently Asked Questions
What is the best painkiller for earache?
Paracetamol or ibuprofen, at the correct dose for age and weight, taken regularly for the first 48 hours rather than only when the pain peaks. Regular dosing does more for most middle ear infections than an antibiotic would, because most settle within about three days anyway.
How do you use Otigo ear drops?
Four drops into the affected ear canal, two or three times daily, for a maximum of 7 days. They are a local painkiller containing phenazone and lidocaine, not an antibiotic. They must not be used if the eardrum is perforated, and treatment should be stopped and advice sought if discharge develops.
Why did I get ear drops instead of antibiotics?
Because most middle ear infections settle without antibacterial treatment, and the symptom that needs treating is pain. Analgesic ear drops treat that directly and can avoid an antibiotic course for an infection that was going to resolve anyway. Antibiotics are used where someone is very unwell, at high risk, or not improving.
Do antibiotic ear drops work for a middle ear infection?
Not with an intact eardrum, because they cannot get through it. Antibiotic drops treat infections of the ear canal. A middle ear infection behind an intact eardrum is treated with pain relief and, where indicated, oral antibiotics.
How do I put ear drops in so they work?
Warm the bottle in your hand, lie with the affected ear uppermost, pull the ear up and back in an adult or down and back in a young child, put in the full number of drops aimed at the canal wall, stay lying down for three to five minutes, and press the tragus gently a few times to pump them along.
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.