Middle Ear or Outer Ear?
One test tells them apart in a second, and they are treated completely differently — plus earwax, a burst eardrum, and the earache that is not coming from the ear.
Part of the Complete Ear Infection Guide.
Key fact: One test separates them in a second. Does touching the ear hurt? Pulling the earlobe or pressing the small flap in front of the canal is painful in an outer ear infection and not in a middle ear one — and the two are treated completely differently.
The test that separates them
Press the tragus — the small flap of cartilage in front of the ear canal — or gently pull the earlobe downwards and back.
| Result | Points to |
|---|---|
| It hurts, sometimes sharply | Outer ear infection — the inflamed skin of the canal is being moved |
| It does not change the pain | Middle ear infection — the problem is behind the eardrum, where touching cannot reach it |
It is not infallible, but it is the single most useful thing you can do at home, and it points at two quite different treatments.
Middle ear infection
Otitis media. Fluid and inflammation build up in the air-filled space behind the eardrum, usually when the Eustachian tube — which normally drains it into the back of the nose — is blocked by a cold.
- Follows a cold by a few days, typically
- Commonest in young children, whose drainage tubes are shorter, narrower and more horizontal
- Deep, throbbing pain, often worse lying down
- Muffled hearing and a feeling of fullness
- Fever is common, particularly in children
- Touching the ear does not make it worse
- In a baby or toddler: pulling at the ear, unsettled, off their feed, waking in the night, off balance
Outer ear infection
Otitis externa, or swimmer's ear. Infection of the skin lining the ear canal itself.
- Itch usually comes first, sometimes for days before any pain
- Pain becomes disproportionate — a canal that looks only mildly inflamed can be extremely painful, because the skin is tightly bound to bone with nowhere to swell
- Touching or moving the ear hurts
- Discharge from the canal, sometimes smelly
- A blocked, full feeling as the canal swells
- Triggers: swimming, showering, humid weather, cotton buds, earplugs, hearing aids, and eczema or psoriasis in the canal
- Adults more than children
Side by side
| Feature | Middle ear | Outer ear |
|---|---|---|
| Pain on touching the ear | No | Yes |
| Itch | Uncommon | Common, often first |
| Preceded by a cold | Usually | Not typically |
| Preceded by water or cotton buds | No | Often |
| Fever | Common | Uncommon unless spreading |
| Discharge | Only if the eardrum perforates | Common |
| Who | Mostly children | Mostly adults |
| Treatment | Pain relief; antibiotics sometimes | Ear drops; oral antibiotics rarely |
Earwax
Impacted wax causes some of the same symptoms — blocked hearing, fullness, mild discomfort — and none of the infection. What it does not usually cause is significant pain or fever.
- Wax is protective, slightly acidic and water-repellent, and the canal clears itself naturally
- Cotton buds push it inwards, compact it against the eardrum, and scratch the canal — which is how wax removal attempts cause outer ear infections
- Softening drops such as olive oil are the usual first step for genuine impaction
- Never use ear candles, or attempt to dig wax out
- Do not use softening drops if the eardrum may be perforated or there is discharge
A burst eardrum
A middle ear infection can build up enough pressure to perforate the eardrum. The pattern is distinctive:
- Severe pain that suddenly eases, often in the middle of the night
- Discharge appears at the same moment — the pressure has been released
- Hearing is reduced on that side
- It usually heals on its own over a few weeks
- It changes what is safe to put in the ear, which is the practical point
Analgesic ear drops containing phenazone and lidocaine must not be used where the eardrum is perforated — the licence and the Pharmacy First criteria both exclude it, because the drops can reach middle ear structures. If discharge develops while using them, stop and get advice. Some antibiotic drops are also unsuitable with a perforation, so it always needs mentioning.
When the ear is not the problem
Earache with a normal-looking ear is common, particularly in adults, and the pain is often referred from somewhere nearby:
- Teeth — a decayed or impacted lower molar is the classic cause
- The jaw joint — pain in front of the ear, worse chewing, often with clicking and associated with grinding
- The throat and tonsils — pain referred upwards, especially on swallowing. See sore throat
- The sinuses — pressure and fullness rather than sharp pain
- The neck — muscular or spinal problems referring to the ear
Persistent one-sided earache in an adult with a normal ear examination — particularly a smoker or heavy drinker, or alongside hoarseness, a neck lump, difficulty swallowing or unexplained weight loss — should be assessed rather than repeatedly treated. Referred pain can be the presenting symptom of a head and neck cancer.
Why getting it right matters
| If it is | What helps | What does not |
|---|---|---|
| Middle ear infection | Regular pain relief; analgesic drops where the eardrum is intact; antibiotics in specific circumstances | Antibiotic ear drops, which cannot get through an intact eardrum |
| Outer ear infection | Ear drops applied into the canal; keeping the ear dry | Oral antibiotics in most cases — they reach the canal skin poorly |
| Earwax | Softening drops, and leaving it alone | Antibiotics of any kind; cotton buds |
| Referred pain | Finding and treating the actual source | Anything applied to the ear |
Earache treatment and when antibiotics are needed covers what to do once you have worked out which one you are dealing with.
Press the small flap of cartilage in front of the ear canal, or gently pull the earlobe. If that hurts, it points to an outer ear infection, where the inflamed canal skin is being moved. If it makes no difference, it points to a middle ear infection behind the eardrum. Itch coming first also suggests the outer ear, and a preceding cold suggests the middle ear. In outer ear infections the skin lining the canal is tightly bound to bone with almost nowhere to swell, so even modest inflammation produces severe pain. The appearance frequently understates how painful it is. Wax itself is protective and the canal clears itself naturally. Attempts to remove it are the problem: cotton buds push wax inwards, compact it against the eardrum and scratch the canal, which is a common way outer ear infections start. The usual pattern is severe pain that suddenly eases, often at night, with discharge appearing at the same moment and reduced hearing on that side. It normally heals on its own over a few weeks, but it changes what is safe to put in the ear, so it needs mentioning. Earache with a normal-looking ear is usually referred pain, most often from the teeth, the jaw joint, the throat or the sinuses. Persistent one-sided earache in an adult with a normal examination, especially with hoarseness, a neck lump, swallowing difficulty or weight loss, should be assessed rather than treated repeatedly.Frequently Asked Questions
How do I know if it is an outer or middle ear infection?
Why does my ear hurt so much when it does not look bad?
Can earwax cause an ear infection?
How do I know if my eardrum has burst?
My ear hurts but the doctor says it looks normal. What now?
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.