Ear Infection: A-to-Z Guide from Diagnosis to Treatment to Prevention

Acute otitis media (AOM) refers to fluid in the middle ear accompanied by symptoms of an ear infection, such as pain, redness, or a bulging eardrum.

Introduction to ear infection:

Many parents are familiar with being awoken by a crying baby with an ear infection. Ear infections are the most common reason that children take an extra trip to the doctor, take antibiotics, or even have surgery.

What is it?

Ear infections come in several varieties. Most people use the phrase “ear infection” to refer to otitis media, an inflammation of the middle ear behind the eardrum. Otitis media with effusion (OME) is the name for fluid in the middle ear without other symptoms. Children with OME act as if they feel well. Because it is often discovered on routine well-child checks, it is sometimes called silent otitis media. Acute otitis media (AOM) refers to fluid in the middle ear accompanied by signs or symptoms of an ear infection, such as pain, redness, or a bulging eardrum. Children with AOM act sick (especially at night) and often have fevers. When children are taken to the doctor because they seem to have an ear infection, the visit is usually about AOM. This article is also about AOM. Many different species of bacteria and viruses can infect the middle ear. Some are quite aggressive; others are slow and stubborn. The Eustachian tube is a small canal that connects the middle ear to the back of the throat. When bacteria make their way into the middle ear, they are supposed to be flushed out through the Eustachian tube. When the Eustachian tube is blocked, or isn’t functioning properly, germs can become trapped in the middle ear. This causes an ear infection.

Who gets it?

Ear infections are most common in someone who already has an upper respiratory infection. Children get ear infections much more often than adults. The highest concentration of ear infections occurs in the window between 6 and 24 months of age. About a third of children get no ear infections; about one third have occasional ear infections (three or less in any one year); and about one third are prone to ear infections. Children may be prone to ear infections for a variety of reasons. Some have immature immune systems; some have Eustachian tubes that are shorter, narrower, or less efficient; and some have other reasons that the Eustachian tube is more likely to become inflamed or blocked (such as allergies, GE reflux, or environmental irritants like tobacco smoke). In the Northern hemisphere, ear infections are most common between December and March, even in areas with a mild climate. They are least common between July and September. Ear infections are also more common among children in day care, especially if a child is exposed to more than six other children or if the child uses a pacifier.

What are the symptoms?

Even though ear tugging is one of the most common reasons that children are brought to the doctor, ear tugging is not a specific symptom of an ear infection. Young children like to tug on ears. They might tug more if there is fluid in the ear or if the ear feels funny. Nevertheless, careful research has verified that ear tugging by no means occurs exclusively in children with AOM. AOM hurts. Pain builds as pressure in the ear builds. It may go away and then come back. The pain is usually worse at night. In an older child, “My ear hurts!” is the most reliable symptom. In a younger child, the best clue is evidence of pain, such as crying, screaming, fussiness (worse when lying down), or sudden increased difficulty sleeping. Hearing is decreased and there may be a feeling of fullness in the affected ear. Again, an older child might comment on this; a younger one might shake his head or might give no sign of the fluid. One-third to one-half of children with ear infections develop fevers. Fevers are more common in infants and toddlers. Although there are many other causes, the combination of fever and pain is most often an ear infection in infants and toddlers. Some children with ear infections will have loose stools or vomiting or other symptoms of general illness. The symptoms listed above are even more suggestive if it is winter or if there is an obvious reason the Eustachian tube might be blocked (a cold or other upper respiratory infection, a change in elevation, exposure to cigarette smoke, or drinking a bottle lying on the back).

Are they contagious?

Ear infections themselves are not contagious. Nevertheless, the upper respiratory infections that often set up ear infections are quite contagious. The same upper respiratory virus might spread throughout a group of children. They might all catch colds, but only those who are otitis-prone might end up with ear infections. Nevertheless, these ear infections might all be caused by different bacteria and respond to different antibiotics!

How long do they last?

Once antibiotics are started, the symptoms should not continue to get worse. Fever and pain should be dramatically improved or gone within 48 to 72 hours. Painless fluid in the ear typically lasts for weeks or months following AOM, during which time the child’s hearing is decreased and the child is more vulnerable to another episode of AOM. Most children with AOM would also get better without antibiotics. The time frame described above is typically delayed by one day at every point for children who are untreated (unless they develop complications). Most do not develop complications. Meningitis is a rare complication that can begin as an untreated ear infection.

How are they diagnosed?

A skilled observer can make the diagnosis by looking in the ears with an otoscope. Ear infections tend to be over-diagnosed in young children with red eardrums. Eardrums can be red in AOM, but they can also be red from crying or from a fever. To confirm the presence of AOM, it is important to confirm the presence of fluid in the ear. This may be accomplished while looking in the ear with an otoscope by using a small rubber bulb to push air against the eardrum. Alternatively, this may be accomplished with automatic devices such as a tympanogram or an acoustic reflectometer. If there is a hole in the eardrum, fluid may be draining through the hole. When specific, accurate diagnosis is important, some of the infected fluid may be obtained with a swab (if there is already a hole) or with a needle (if the eardrum is intact). Culturing this fluid can pinpoint the species of bacteria involved and the best antibiotics for that particular strain. This is usually not necessary.

How are they treated?

Many ear infections can resolve on their own, without antibiotics. Healthy, older children can often be treated with pain killers and close follow up. If symptoms are severe, persist, or worsen, then antibiotics are considered. For children who are young or at risk for complications, antibiotics may be indicated to speed recovery, reduce pain, and prevent complications. For children on antibiotics, if the child is not dramatically better within 48 to 72 hours, the antibiotics should be switched to something stronger. Beyond this, repeated changes or rounds of antibiotics are usually not helpful. Whether or not they are treated with antibiotics, children with AOM deserve something to alleviate their pain (though usually this should not be needed for more than 72 hours). Choices might include oral pain medicines, anesthetic eardrops, or warm compresses on the ear. Antihistamines, decongestants, and steroids have not been shown to be effective in treating AOM.

How can they be prevented?

Preventing ear infections involves:

  1. Decreasing your child’s exposure to ear infection-causing bacteria
    • a. Keep day care size to six or fewer children (especially in the winter months for children under age 2)
    • b. Stop giving them a pacifier. Sucking on a pacifier can pull germs into the middle ear. Avoiding pacifiers can reduce ear infections by 50 percent for children in day care.
    • c. Xylitol is a natural sweetener found in raspberries and plums. Most sugars promote bacterial growth. Xylitol inhibits it. Gums, lozenges, and syrups containing sufficient xylitol have been shown to be effective at reducing ear infections by almost half.
    • d. The respiratory infections that lead to ear infections are often spread by touch or by fomites. Frequent hand washing and cleaning of toys are both helpful.
    • e. Respiratory infections can also spread through the air. Avoid staying in small rooms with sick people and poor air circulation. Fresh air and HEPA filters can help.
  2. Increasing your child’s immunity to ear infection-causing bacteria
    • a. Breastfeeding is quite powerful at reducing the number of ear infections. Nursing throughout the first year is best, but even a few weeks of breastfeeding results in fewer ear infections for the next three years!
    • b. The pneumococcal vaccine and the flu vaccine have both been demonstrated to help in the prevention of ear infections.
    • c. Good nutrition, plenty of sleep, and decreased stress all help to bolster immunity.
  3. Ensuring proper Eustachian tube function
    • a. Avoid passive exposure to cigarette smoke. Up to 2 million ear infections are caused by passive smoking each year in the US.
    • b. Avoid having your child drink while lying flat on his back.
    • c. Identify and treat allergies. Up to 40 percent of ear infections are caused in part by Eustachian tubes swollen by allergies. Dust is the most common airborne allergen. There may be an association between cow’s milk allergy and otitis media in a small number of children.
    • d.Identify and treat GE reflux. Research published in 2002 suggests that in some children with frequent ear infections, undiagnosed GE reflux is responsible for the inflammation of the Eustachian tube.

Acute otitis media, otitis media, AOM


Last medical review on: January 02, 2009
About the Author
Photo of Alan Greene MD
Dr. Greene is a practicing physician, author, national and international TEDx speaker, and global health advocate. He is a graduate of Princeton University and University of California San Francisco.
Get Dr. Greene's Wellness RecommendationsSignup now to get Dr. Greene's healing philosophy, insight into medical trends, parenting tips, seasonal highlights, and health news delivered to your inbox every month.