Ear infections

The words "my ear hurts" cover at least three different illnesses, and each is treated in its own way. One starts on the outside, in the ear canal, and usually has something to do with water. Another sits behind the eardrum and tends to arrive a few days after a runny nose — this is the one that wakes children in the small hours. The third involves the inner ear, and its main complaint is not pain but the feeling that the room is moving. Most of these stories settle within days with no treatment at all. But the ear has an awkward feature: the skull begins just behind it, and its rare complications move fast. What follows is how to tell them apart, and the point at which waiting at home should stop.

Three floors of one organ

Which floor is inflamed can usually be worked out before anyone examines the ear, simply from what is bothering the person.

• The outer ear. Inflammation of the skin lining the canal. The ear itches first, then starts to hurt, and the pain jumps sharply if you pull the earlobe or press the little flap in front of the opening. Hearing goes muffled because of the swelling, and there may be some discharge. The cause is water left in the canal after swimming, the habit of cleaning ears with cotton buds, in-ear headphones, eczema or psoriasis. The germ arrives second, onto skin that is already damaged.
• The middle ear. The cavity behind the eardrum. It is ventilated by the eustachian tube running down to the back of the nose; during a cold the tube swells and stops working, fluid gathers in the cavity, and infection travels up from the nose. Hence the order of events: two or three days of a cold first, then pain at night. Pulling on the ear does not hurt, because the pain is deep inside.
• The inner ear. Home to the cochlea and the balance organ. Inflammation here gives not pain but severe dizziness with nausea, sometimes ringing and loss of hearing on one side. It is nearly always viral, and it lasts longer — days and weeks, improving gradually.

What it looks like in children

A child under two or three will not say that an ear hurts. Their eustachian tube is shorter and lies flatter, so the middle ear becomes inflamed far more readily than in an adult. Worth noticing:

• crying that gets worse on being laid down and settles when the child is held upright;
• a hand that keeps going back to the same ear;
• refusing the breast or the bottle, because sucking sends pain into the ear;
• a temperature and a bad night on the third or fourth day of an ordinary cold;
• a child who suddenly calms: they had been sleeping badly, then abruptly settled, and there is a yellowish patch on the pillow. That is the eardrum perforating, the pressure dropping and the pain going with it. It sounds alarming, but the hole almost always closes by itself within a couple of weeks.

There is a separate chapter that involves no pain at all, only quiet. If after an ear infection a child starts saying "what?", turning the television up and responding less reliably to their own name, fluid may have been sitting behind the eardrum for months. It does not hurt, which is why it gets missed, and for speech at that age a few months of muffled hearing is a long stretch. That is a reason to have hearing tested rather than to keep waiting.

What to do in the first few days

If the person is otherwise well and the ear is the only problem, the first two or three days are usually spent watching.

• Painkillers are not for "when it becomes unbearable" — they are taken from the start and by the clock on the first day. Pain relief, not drops and not antibiotics, is what settles the pain. Ordinary over-the-counter medicines do the job; which one suits you or your child is a question for a doctor or a pharmacist. Aspirin is not given to children or teenagers.
• Dry warmth over the ear helps many people. The pad should be warm rather than hot, and it is not used if the ear is discharging.
• Sleeping propped up on two pillows is better: lying flat always makes the pain worse.
• The ear needs to be kept dry. For showering, a ball of cotton wool smeared with petroleum jelly at the entrance to the canal; swimming waits until the ear has recovered.
• Discharge is wiped away gently on the outside with cotton wool. Nothing goes inside — no cotton buds, no finger, no rolled-up gauze.
• Decongestant nose drops and antihistamines do nothing for a middle ear infection; this has been tested and does not hold up. They may dry the nose, but they leave the ear alone.
• Putting drops in an ear nobody has looked into is a poor idea, particularly if it is discharging. Some preparations must not go in through a perforated eardrum, and from the outside there is no way of knowing whether it is intact.

When waiting at home should stop

It is worth being seen within a day or two if the pain is unchanged on the third day, if the ear has started to discharge, if the patient is a baby under a year old, if the temperature stays up despite medicine for fever, or if ears keep becoming infected. A separate group are people with diabetes, with weakened immunity or having chemotherapy: in them outer ear infection behaves differently and is taken more seriously from the outset.

These signs, though, mean emergency care, and there is no waiting until morning:

• the skin behind the ear has gone red, hot and swollen, and the ear itself looks pushed forward — that is infection spreading into the mastoid, the bone behind the ear;
• the face has dropped: the eye will not close, the eyebrow will not lift, the corner of the mouth sags on the side of the sore ear;
• severe headache with vomiting, a stiff neck, drowsiness, confusion, fits, discomfort in the light, a rash that does not fade when pressed with a clear glass;
• sudden violent dizziness with vomiting that makes standing impossible, especially together with loss of hearing;
• hearing that disappears abruptly, over minutes or hours, on one side and without pain. This is not wax and not a draught: sudden deafness has a narrow window in which treatment works, and it is counted in days;
• ear pain that prevents sleep and is not touched by painkillers, in someone with diabetes or poor immunity — a rare but dangerous form of outer ear infection that tracks into the bone at the base of the skull;
• in a baby of a few months, a temperature above 38 degrees, floppiness, refusing feeds, an unusual monotonous cry.

In those situations call an ambulance; across Europe the single number is 112.

What actually treats it

The approach depends on which floor is involved, and the difference matters.

In an outer ear infection the mainstay is local treatment: the canal is cleaned and drops are prescribed — antibacterial, antifungal or with a steroid, depending on what is seen. Antibiotic tablets are usually unnecessary here, because they reach the skin of the canal less well than a drop landing directly on it. Drops only work if they genuinely get to the bottom: lie on your side with the sore ear uppermost, put the drops in, pull the outer ear gently back and up so the canal straightens, and stay lying down for a few minutes. Half of all "useless" drops have simply run back out within thirty seconds.

In a middle ear infection antibiotics are far from always needed. In most children over two with a modest temperature and moderate pain the whole thing settles by itself, and the sensible plan is pain relief with a review after forty-eight hours. Antibiotics are given straight away if the ear is discharging, if both ears are affected in a small child, if the child is very young, if they are generally unwell, or if there are risk factors. Usually these are penicillins, or other families where there is an allergy; the course is finished even though the pain went on day two.

In inner ear inflammation antibiotics contribute nothing, because the cause is viral. Dizziness and nausea are treated, and after that the brain recalibrates itself to the altered signal — a process helped by movement rather than rest. Normal walking should be resumed sooner than it feels comfortable to.

A boil in the canal is drained if necessary. If fluid behind the eardrum has been there for months and a child is not hearing properly, a tiny ventilation tube, a grommet, is discussed; it airs the cavity until the eustachian tube starts working again on its own.

What cuts down repeat infections

Complete prevention is not on offer: half of these infections begin with an everyday cold. But a few things genuinely change how often they come.

• Tobacco smoke at home is one of the best-established factors. Smoking at an open window or on the balcony does not solve it — the smoke stays on clothing and in the air of the room.
• Routine childhood vaccinations, particularly against pneumococcus and flu, noticeably reduce the number of episodes.
• Breastfeeding in the early months lowers the risk; bottle-feeding a baby lying flat on their back does not help.
• A dummy is phased out gradually after the first six months — with recurrent ear infections this is one of the few things parents can change themselves.
• Cotton buds are not used at all. They do not clean the ear: they push wax further in and scratch the skin, which is the route the infection takes.
• Swimmers are helped by earplugs or a cap that covers the ears, and by the habit of tipping the head to let water run out afterwards.
• Eczema, psoriasis and allergy to a hearing-aid mould need treating: inflamed canal skin becomes infected more easily.

Online consultation

Remotely, the key question of the first day gets answered: watch at home, or go and have the ear looked into. The doctor will go through how it started, whether a cold came first, whether touching the outside of the ear hurts, whether there is discharge and fever, will advise on pain relief for a child and the dose for their weight, and will name the signs at which waiting stops. It is also a convenient way to decide what to do about an ear still hearing poorly a month after an infection, or about ears that flare several times a year. The emergency signs on the list above are not assessed through a screen — with those you go straight to emergency care.

This material is for information only and does not replace medical advice.