Ear Infections

What Are Ear Infections?

Ear infections are among the most common reasons for GP consultations in the United Kingdom. According to the Royal College of General Practitioners (RCGP), ear infections account for a significant proportion of all primary care appointments, with an estimated 10 million GP consultations per year in the UK relating to ear, nose, and throat complaints — of which ear infections represent the single largest category. They are particularly prevalent in children: NHS data shows that approximately 75% of children will experience at least one ear infection before they reach school age, and they are the most common reason for antibiotic prescriptions in paediatric primary care.

Ear infections are classified by their location within the ear, and understanding which part of the ear is affected is essential for correct diagnosis and treatment. The three principal types are otitis externa (outer ear infection), otitis media (middle ear infection), and labyrinthitis (inner ear infection). Each has distinct causes, symptoms, and treatment pathways. While the vast majority of ear infections resolve without lasting consequences, recurrent or poorly managed infections can lead to temporary or, in rare cases, permanent hearing loss — making prompt recognition and appropriate treatment important for long-term hearing health.

Types of Ear Infection

Otitis Externa (Outer Ear Infection)

Otitis externa — commonly known as swimmer's ear — is an infection or inflammation of the ear canal, the passage that runs from the outer ear to the eardrum. It is estimated to affect around 1 in 10 people at some point in their lives (NICE Clinical Knowledge Summary, 2023). The condition is most common in adults aged 45–75 and in people who swim regularly, though it can affect anyone at any age.

The ear canal is normally protected by a thin layer of earwax (cerumen) that creates a slightly acidic, water-repellent barrier against infection. Otitis externa develops when this natural defence is disrupted. The most common causes include:

• Water exposure: Swimming, showering, or bathing can leave moisture trapped in the ear canal, creating a warm, damp environment in which bacteria (most commonly Pseudomonas aeruginosa and Staphylococcus aureus) thrive.
• Trauma to the ear canal: Inserting cotton buds, fingernails, hearing aids, or ear plugs can scratch or irritate the delicate skin lining the canal, allowing bacteria or fungi to enter.
• Skin conditions: Eczema, psoriasis, and seborrhoeic dermatitis affecting the ear canal increase susceptibility to infection.
• Fungal infection: In approximately 10% of cases, otitis externa is caused by fungi (most commonly Aspergillus or Candida species) rather than bacteria — this is known as otomycosis and is more common in warm, humid climates and in people who have used prolonged courses of antibiotic ear drops.

Symptoms of otitis externa include ear pain that is often severe — particularly when the outer ear (pinna) is touched or pulled — itching, discharge from the ear canal, a feeling of fullness or blockage, and temporary hearing loss caused by swelling or debris in the canal. If you are experiencing these symptoms, a standard hearing test after the infection resolves can confirm whether your hearing has returned to normal.

Otitis Media (Middle Ear Infection)

Otitis media occurs when the space behind the eardrum becomes infected and inflamed, usually following a cold, flu, or upper respiratory tract infection (URTI). It is the most common type of ear infection in children: NICE estimates that approximately one in four children will experience at least one episode of acute otitis media (AOM) by their first birthday, and it accounts for around 30% of all GP consultations for children under five.

The middle ear is normally an air-filled space connected to the back of the throat via the Eustachian tube. In children, the Eustachian tubes are shorter, more horizontal, and narrower than in adults, making them more easily blocked by swelling or mucus during a cold. When the Eustachian tube becomes blocked, fluid accumulates in the middle ear, providing an ideal environment for bacteria or viruses to multiply. The most common bacterial causes are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Viral causes include respiratory syncytial virus (RSV), rhinoviruses, and influenza.

Symptoms of otitis media include earache (often intense and throbbing), fever — particularly in young children — irritability, poor feeding or sleep disturbance in infants, temporary hearing loss or muffled hearing, and occasionally discharge from the ear if the eardrum perforates (a perforated eardrum). If fluid persists in the middle ear for weeks or months after the acute infection resolves, this is known as otitis media with effusion — commonly called glue ear — and is the most common cause of hearing loss in children in the UK.

Labyrinthitis (Inner Ear Infection)

Labyrinthitis is an infection or inflammation of the labyrinth — the fluid-filled structure in the inner ear responsible for both hearing and balance. It is less common than otitis externa or otitis media but can be considerably more distressing. Labyrinthitis is most commonly caused by viral infections, including those that cause colds, flu, measles, and mumps. Less commonly, it can result from a bacterial infection spreading from the middle ear or from the membranes surrounding the brain (meningitis).

The hallmark symptoms of labyrinthitis are sudden onset of vertigo (an intense spinning sensation), nausea and vomiting, hearing loss in the affected ear, and tinnitus. Because the inner ear controls both hearing and balance, inflammation here can produce a particularly disabling combination of symptoms. Most cases of viral labyrinthitis resolve within a few weeks, but some people experience residual balance problems for several months. A hearing assessment is recommended after recovery to check whether any hearing loss persists.

How Are Ear Infections Diagnosed?

Accurate diagnosis of an ear infection involves identifying which part of the ear is affected and whether the cause is bacterial, viral, or fungal. GPs and audiologists use several methods:

• Otoscopy: The most fundamental examination, using a handheld otoscope to look directly into the ear canal and at the eardrum. In otitis externa, the ear canal appears red, swollen, and may contain discharge or debris. In otitis media, the eardrum may be red, bulging, or retracted, and fluid may be visible behind it. A perforated eardrum will show a visible hole with possible discharge.
• Tympanometry: This quick, painless test measures the movement of the eardrum in response to changes in air pressure. A flat tympanogram (Type B) strongly suggests fluid behind the eardrum, which is characteristic of otitis media or glue ear. Tympanometry is particularly valuable in young children who cannot reliably report their symptoms.
• Pure tone audiometry: A standard hearing test to assess whether the infection has caused any measurable hearing loss. This is especially important in children with recurrent infections, where cumulative hearing loss can affect speech and language development.
• Otoacoustic emissions (OAE) testing: Used primarily in newborns and young children, this test measures sounds produced by the healthy inner ear in response to stimulation. Absent or reduced emissions may indicate inner ear dysfunction or middle ear fluid.

In most straightforward cases, a GP can diagnose an ear infection based on symptoms and otoscopy alone. More complex or recurrent cases may warrant referral to an ENT specialist for further investigation, including imaging and specialist audiological assessment.

Treatment: How Ear Infections Are Managed

Otitis Externa

Treatment for outer ear infections typically involves antibiotic or antifungal ear drops, depending on the causative organism. NICE recommends topical treatment as first line — commonly a combination of an antibiotic (such as ciprofloxacin or neomycin) with a corticosteroid to reduce inflammation. If fungal infection is suspected, antifungal drops (such as clotrimazole) are used instead. In severe cases or where the ear canal is very swollen, an ear wick (a small sponge) may be inserted to help deliver the drops deeper into the canal. Professional microsuction or ear cleaning may be needed to remove debris before treatment can be effective. Pain relief with paracetamol or ibuprofen is recommended alongside topical treatment. Patients are advised to keep the ear dry — avoiding swimming, and using a cotton ball lightly coated in petroleum jelly during showering — until the infection has fully resolved.

Otitis Media

The management of acute otitis media has changed considerably over the past two decades. NICE clinical guideline NG91 now recommends a "watch and wait" approach for the first 48 to 72 hours in most children over two years of age with uncomplicated AOM. During this period, pain should be managed with regular paracetamol or ibuprofen at appropriate doses for the child's age. Research published by NICE shows that approximately 80% of acute middle ear infections resolve spontaneously without antibiotics.

Antibiotics (usually amoxicillin as first line) are recommended in the following situations:

• Children under two years with bilateral acute otitis media
• Children or adults with otorrhoea (discharge from a perforated eardrum)
• Patients who are systemically unwell or at high risk of complications
• Symptoms that worsen or fail to improve after 48–72 hours of watchful waiting

This approach is supported by RCGP guidance and aligns with antimicrobial stewardship principles — reducing unnecessary antibiotic use helps combat antibiotic resistance, which Public Health England has identified as one of the most serious health threats facing the UK.

Labyrinthitis

Viral labyrinthitis is managed supportively. During the acute phase, anti-emetics (such as prochlorperazine) and vestibular sedatives (such as cinnarizine or betahistine) may be prescribed to manage vertigo and nausea. Bed rest is often necessary during the most severe symptoms. Corticosteroids may be used in some cases to reduce inner ear inflammation. Bacterial labyrinthitis — which is much rarer and more serious — requires urgent hospital treatment with intravenous antibiotics. After the acute phase, vestibular rehabilitation exercises are recommended to help the brain compensate for any residual balance disturbance.

Recurrent Ear Infections in Children: When to Seek Specialist Help

While most children experience occasional ear infections that resolve without lasting effects, some children suffer from recurrent acute otitis media — defined as three or more episodes in six months, or four or more in twelve months. Recurrent infections are more common in children who:

• Attend nursery or childcare settings (due to increased exposure to respiratory infections)
• Are exposed to secondhand smoke
• Were not breastfed, or were breastfed for less than three months
• Use a dummy (pacifier) beyond six months of age
• Have older siblings in school (increasing household exposure to URTIs)
• Have underlying conditions such as Down syndrome, cleft palate, or primary immunodeficiency

NICE recommends referral to an ENT (ear, nose, and throat) specialist for children with recurrent acute otitis media, persistent otitis media with effusion (glue ear) lasting more than three months with associated hearing loss, or suspected complications such as cholesteatoma. The ENT specialist may recommend grommets (tympanostomy tubes or ventilation tubes) — tiny tubes inserted through the eardrum under general anaesthetic to allow air into the middle ear and prevent fluid build-up. Grommet insertion is one of the most commonly performed childhood operations in the UK, with RNID noting that approximately 25,000–30,000 grommet procedures are carried out each year in England alone. Grommets typically remain in place for 6–18 months before falling out naturally as the eardrum heals. A children's hearing test is recommended before and after grommet insertion to monitor hearing levels.

In some cases, removal of the adenoids (adenoidectomy) may be recommended alongside grommet insertion, as enlarged adenoids can contribute to Eustachian tube blockage and recurrent infections.

Ear Infections and Hearing Loss

One of the most important consequences of ear infections — particularly for parents to understand — is the relationship between ear infections and hearing loss. The nature and duration of hearing loss depends on the type and severity of the infection:

• Temporary conductive hearing loss: The most common outcome. Fluid or swelling in the middle ear or ear canal physically blocks sound from reaching the inner ear. This typically resolves completely once the infection clears and fluid drains. However, if fluid persists for weeks or months (as in glue ear), the hearing loss can have a significant impact on a child's speech and language development — particularly during the critical period from birth to three years.
• Persistent hearing loss following recurrent infections: Children who experience repeated middle ear infections may develop scarring of the eardrum (tympanosclerosis) or damage to the tiny bones of the middle ear (ossicles), leading to longer-lasting conductive hearing loss. RNID estimates that glue ear is the most common cause of hearing difficulty in children in the UK, affecting around 8 in 10 children at some point before the age of 10.
• Sensorineural hearing loss: In rare but serious cases — particularly with bacterial labyrinthitis or severe complications of otitis media such as cholesteatoma — the infection can damage the delicate structures of the inner ear, resulting in permanent sensorineural hearing loss. This underscores the importance of seeking prompt medical attention for severe or complicated ear infections.

If you or your child has experienced an ear infection and hearing does not seem to have returned to normal within two to four weeks, it is important to arrange a hearing assessment. Early identification of any residual hearing loss allows for timely intervention — whether that is watchful waiting, medical treatment, grommets, or hearing aids. You can search for audiologists near you to book an appointment, or ask your GP for a referral to NHS audiology. High-street providers such as Boots Hearingcare, Specsavers Audiology, and Hidden Hearing also offer hearing assessments.

Prevention: Reducing the Risk of Ear Infections

While ear infections cannot always be prevented, several evidence-based measures can significantly reduce the risk — particularly for children who are prone to recurrent episodes:

• Keep ears dry: After swimming or bathing, tilt the head to each side to allow water to drain from the ear canals. Dry the outer ear gently with a towel. Swimmers may benefit from well-fitted ear plugs or a neoprene headband to keep water out. For more detail, see our guide on swimmer's ear prevention.
• Avoid cotton buds and other objects: Never insert cotton buds, fingers, hairpins, or other objects into the ear canal. These can damage the delicate lining, push earwax deeper, and remove the ear's natural protective barrier. Professional ear wax removal by microsuction or irrigation is the safe alternative if you experience wax build-up.
• Breastfeed for at least six months: Research published by NICE and the World Health Organization shows that breastfeeding provides antibodies that help protect against ear infections. Babies who are breastfed for six months or longer have significantly fewer episodes of acute otitis media.
• Keep vaccinations up to date: The pneumococcal conjugate vaccine (PCV), which is part of the routine NHS childhood immunisation schedule, protects against Streptococcus pneumoniae — one of the leading bacterial causes of otitis media. The annual flu vaccine can also reduce the incidence of ear infections by preventing the respiratory viruses that often precede them.
• Avoid secondhand smoke: Children exposed to tobacco smoke have a significantly higher risk of ear infections. NHS guidance strongly advises against smoking in the home or car, and around children.
• Manage allergies and colds promptly: Treating nasal congestion and allergic rhinitis helps keep the Eustachian tubes clear. Saline nasal sprays and age-appropriate decongestants can be helpful during colds.
• Feed infants upright: Bottle-feeding a baby while they are lying flat can allow milk to flow into the Eustachian tubes, increasing infection risk. Holding the baby at a 45-degree angle or more during feeds reduces this risk.
• Treat Eustachian tube dysfunction early: If you or your child frequently experiences a blocked or popping sensation in the ears, this may indicate Eustachian tube dysfunction, which predisposes to middle ear infections. Your GP can assess and manage this condition.

When to See a Doctor and Next Steps

Most mild ear infections can be managed at home with pain relief and watchful waiting, but you should see your GP promptly if any of the following apply:

• Ear pain is severe or persists beyond 48 hours despite pain relief
• There is discharge (pus or fluid) from the ear
• A child under two years has symptoms of an ear infection
• You experience hearing loss that does not improve as the infection resolves
• Symptoms worsen despite initial treatment
• There is swelling, redness, or tenderness behind the ear (possible mastoiditis — a medical emergency)
• Vertigo, facial weakness, or severe headache accompany the ear infection
• Ear infections recur frequently (three or more episodes in six months)

If you are concerned about the signs of hearing loss following an ear infection — in yourself or your child — arranging a hearing test is a sensible and straightforward first step. The RNID recommends that children who have experienced recurrent ear infections or persistent glue ear should have their hearing monitored regularly to ensure that any difficulty is identified early and does not affect their development. Our guide on how often you should have a hearing test provides further advice. You can learn more about hearing support available through the NHS hearing services pathway or find an audiologist near you to book a private assessment.