Ear infection is a catch-all term—but not all ear infections are the same. There are two main types of ear infections, and it’s important to understand the differences, what causes them and how they should be treated. Bottom Line Personal asked board-certified otolaryngologist and neurotologist Matthew Shew, MD, what you need to know.
Location Matters When It Comes to Ear Infections
The type of ear infection you have depends on where it’s located within the ear…
Otitis media is an infection behind the eardrum, often called a middle-ear infection. This type of infection is relatively common in children, but they can occur in adults as well. With appropriate treatment—typically oral antibiotics—most adults experience relief from pain and infection-related symptoms within a few days. But it is not uncommon for fluid and a sense of pressure in the ear to linger for several weeks even after the infection clears.
Causes of otitis media: The most common risk factor for otitis media is dysfunction of the Eustachian tube. The Eustachian tube helps equalize pressure in the middle ear—something we naturally do when yawning or “popping” our ears on an airplane. When this tube doesn’t function properly, pressure and fluid can build up behind the eardrum, creating an environment prone to infection. The reason otitis media is common in children is because their Eustachian tubes are short, more horizontal and not fully developed, making it harder for fluid to drain. Middle-ear infections often can be set off by viral or bacterial infections linked to upper respiratory infections, colds, allergies or any factors that affect Eustachian tube function. The ear infection itself is not contagious, but the virus that caused the cold or illness that led to the ear infection is.
Symptoms of otitis media: Symptoms usually are felt rather than seen. Common early symptoms include ear pain or pressure, a sensation of fullness and reduced hearing and/or being able to hear fluid in the ear. The challenge is distinguishing simply fluid in the ear from an infection—often pain and pressure can be the differentiating factors. With more serious ear infections, you may have significant ear pain, fever and drainage if the eardrum ruptures. Typically, the outer ear looks normal unless there is a rupture or secondary outer-ear involvement.
Treatment for otitis media: Oral antibiotics often are used for middle-ear infections, especially if symptoms are moderate to severe and persistent. First-line antibiotics for ear infection typically include amoxicillin, which usually is effective against the common bacteria that cause middle-ear infections. Second-line antibiotics often include a broader-spectrum antibiotic such as amoxicillin-clavulanate (Augmentin). If you have a penicillin allergy, alternatives include azithromycin or cefdinir. How long does it take for an ear infection to heal with antibiotics? Typically seven to 10 days.
To reduce risk for otitis media: Manage allergies, nasal congestion and chronic sinus issues with the help of an ear, nose and throat specialist (ENT). In children especially, avoiding exposure to secondhand smoke can help lower risk. If you experience recurrent middle-ear infections—typically four or five within a year—talk to your doctor about whether referral to an ENT for ear tubes may help ventilate the middle ear and prevent fluid buildup.
Otitis externa—often called “swimmer’s ear” or outer-ear infection—is an infection of the ear canal leading to the eardrum. This ear infection is seen more frequently in adults and usually is caused by water exposure, irritation or trauma, or a skin condition.
Causes of otitis externa: Some people are more susceptible to outer-ear infections because of their ears’ anatomical structure or seemingly unrelated dermatologic conditions. Narrow ear canals are more likely to trap moisture and debris, which can lead to infection. Individuals with narrow ear canals or bony growths in the canal (known as exostoses and often seen in surfers and swimmers) are at higher risk for prolonged infections and complications due to the constricted canal space. Other risk factors include frequent water exposure…poking around inside the ear with cotton swabs and other instruments that can irritate or cause trauma to the ear canal…living in warm or humid environments that promote bacterial or fungal growth…and having a skin condition such as eczema or psoriasis. People at greatest risk for very serious otitis externa typically have underlying immune risk factors, such as diabetes or a form of immunosuppression.
Symptoms of otitis externa: For this type of ear infection, you can both sense and see symptoms. People often experience ear pain, itching, a sensation of fullness, ear drainage and tenderness, particularly when the outer ear is manipulated. As the infection worsens, the ear canal can become swollen, and the outer ear may look red and inflamed. In more advanced cases, debris and drainage can accumulate, leading to significant hearing loss (this usually is temporary with the right treatment).
More severe cases of otitis externa can extend into the bone, which is known as malignant otitis externa, and can cause deep, persistent ear pain that doesn’t respond to standard treatments. This requires prompt evaluation and treatment.
Treatment for otitis externa: The treatment mainstay for this type of ear infection is topical therapy with antibiotic ear drops, such as ciprofloxacin or ofloxacin. These drops often are combined with a steroid to help reduce inflammation, particularly if the ear canal is swollen. If the infection is caused by a fungus, particularly after prolonged antibiotic use or when exposed to moist environments, you also might need antifungal ear drops or powders, such as clotrimazole.
While most outer-ear infections resolve within a few days, treating persistent infections—those lasting longer than seven to 10 days—or those that don’t respond to the drops, require in-office treatments. A critical part of these visits usually is cleaning and debriding the ear canal to remove trapped debris, bacteria and/or fungal material and allow the ear drops and other medications to reach the infection site. If you have significant swelling or blockage, your ENT might place a small wick, which acts like a stent, into the ear canal to help open it and deliver the drops more effectively. For very stubborn or multiple recurrent ear infections, your doctor may prescribe more complex powder regimens that not only help dry up moisture in the ear but also deliver a combination of antibiotic, antifungal and steroid agents.
If particularly stubborn or recurrent ear infections are complicated by factors like diabetes or immune suppression, additional steps such as culture-directed therapy (examining a sample of the fluid to identify the specific culprit and better match the infection-fighting drug), imaging or longer courses of treatment may be necessary. Careful follow-up is essential to ensure that the infection fully resolves and to prevent long-term complications, such as permanent hearing loss.
To reduce risk for otitis externa: Take steps to keep moisture out of the ear canal. Preventive strategies include carefully drying the ears after water exposure—you can use a hair dryer on a low setting to dry your ears or an over-the-counter electric ear dryer after showering or swimming. Custom-fitted earplugs can be effective for people who are prone to recurrent outer-ear infections from water exposure. While certain over-the-counter ear drops may help, consult a provider first to ensure the eardrum is intact and that no other underlying conditions are contributing to the problem.
For outer-ear infections, it is particularly important to protect the ear from moisture. Your doctor likely will advise you to avoid swimming, water sports and getting water into the ear while showering or bathing during treatment. Any further water exposure can interfere with the healing process. At home, use an ear plug, a cotton ball lightly coated with Vaseline or a shower cap to shield the ear or ears. For a full recovery and to prevent a recurrence, follow your prescribed treatment plan to the letter, including completing any course of antibiotics or ear drops.
When Ear Infections Escalate
Sometimes ear infections can lead to serious complications. While this is rare, if you’re experiencing either a middle- or outer-ear infection that lasts longer than seven to 10 days, it is important to get a medical evaluation. Prompt diagnosis and treatment by a qualified specialist can prevent more serious outcomes. You might start with your primary care provider, but ask for a referral to a board-certified ENT for persistent or complex ear infections. This is essential if you’re immunocompromised because you’re at risk for the infection spreading rapidly and involving critical structures around the ear, such as the bone, nerves or even deeper tissues.
If a middle-ear infection is left untreated, there is a small but real risk of developing a brain abscess or meningitis. These events typically occur in patients who have additional risk factors, such as an untreated cholesteatoma (a noncancerous skin growth in the middle ear) or a cerebrospinal fluid leak.
For outer-ear infections, particularly in people who are immunocompromised, untreated infections can spread into the bone, leading to a condition called malignant otitis externa. Though also rare, it can become life-threatening.
Getting the right diagnosis, appropriate treatment and being closely monitored by your specialist are critical to prevent these rare but serious outcomes.
