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Overview: Middle ear infection

Last Update: December 22, 2022; Next update: 2025.


Acute middle ear infections (acute otitis media, or AOM) are among the most common illnesses in babies and young children. Most children will have had at least one acute middle ear infection by the age of three. These children then have an earache and fever. It becomes difficult to sleep through the night, and they tend to cry a lot. Their parents also have a restless night ahead, and they may worry that something more serious might be causing the symptoms. But an acute middle ear infection generally goes away on its own within two to three days, and serious complications are very rare.

Giving the child painkillers and fever-reducing medication, as well as a lot of care and attention, is usually enough. But it is important to keep an eye on the child’s condition because further treatment may sometimes be necessary.

At a glance

  • Acute middle ear infections are among the most common illnesses in babies and young children
  • Children usually have a severe earache and fever, sleep poorly, cry a lot and have trouble hearing.
  • An acute middle ear infection usually goes away on its own within two or three days.
  • Giving the child painkillers and providing comfort are key. Antibiotics are only rarely useful.


Acute middle ear infections in young children are typically associated with

  • severe earache,
  • fever over 38°C (100.4°F), and
  • poor hearing, because fluid builds up in the middle ear.

Children often suddenly feel much worse. Some also have to throw up. Young children are often not able to localize pain and may complain of a stomach ache although it's their ears that are hurting. It's also difficult for parents of babies or very young children to know how severe the pain is. Some children shake their heads a lot and hold or rub their ears when they have an earache.

Most of them will have trouble hearing. In general, children who have this kind of infection are more restless, cry more, have a poor appetite and sleep badly. Some children may be weak and quieter than usual, though. Children who have an acute middle ear infection often wake up at night crying because the pain is so bad they can hardly sleep.

Causes and risk factors

Acute middle ear infections usually develop as part of a cold, flu, sore throat or a similar infection. Viruses or bacteria get into the throat and the mucous membranes become inflamed and produce more fluid.

The membranes lining the ear and the Eustachian tube (the canal that connects the middle ear to the throat area) swell up too. As a result, the fluid secreted in the Eustachian tube and the middle ear can no longer drain out. It builds up in the middle ear and pushes on the eardrum. This can be painful and make your hearing worse.

Illustration: Middle ear infection

Middle ear infection

The Eustachian tube is still very narrow and short in babies and toddlers, so germs in their upper throat can easily spread to their middle ear. Middle ear infections are less common after the age of seven because the Eustachian tube and the immune system are more developed.

Enlarged adenoids (“polyps”) can block the middle ear too, increasing the risk of an infection. Further risk factors include allergic reactions and sinus infections. These conditions can lead to swelling in the Eustachian tube, causing inflammation in the middle ear.Children are slightly more likely to get middle ear infections if they

  • use a pacifier (a dummy),
  • often have close contact with other children, for example at daycare or a nursery school,
  • were fed formula from the start rather than mother's milk, or
  • are often exposed to cigarette smoke.

Prevalence and outlook

Middle ear infections are among the most common reasons babies and toddlers are taken to the doctor. By the time they are three years old, 80 out of 100 children have already had a middle ear infection. Up to a third of them have had multiple infections.

Middle ear infections usually clear up on their own within two to three days and generally do not lead to any complications. If the fluid that builds up in the middle ear pushes too hard on the eardrum, the eardrum can burst. The thick, sticky fluid, sometimes also mixed with pus and blood, flows out into the ear canal and the pain gets better. The hole in the eardrum is usually only small and heals on its own within a few days or weeks. A small amount of fluid may continue to drain out of the ear until it heals.

If the infection continues for several weeks, it's considered to be a chronic middle ear infection (chronic otitis media). The earache and fever will go away, but the fluid remains in the middle ear. In many children, fluid mixed with pus will continue to keep on flowing out of their ear.

There is also a risk of permanent hearing loss from persistent infections. Parents can pay attention to how well their child hears and ask about it at their next visit to the doctor.


Sometimes fluid remains in the middle ear after the infection has disappeared and the eardrum has healed. This is called otitis media with effusion (OME), also known as glue ear. Children who have glue ear often feel pressure inside their ear, but rarely experience pain. Glue ear can cause hearing loss, which may delay speech and language development.

If a child has frequent middle ear infections and the eardrum ruptures again and again, this thin membrane may become scarred. This can make the eardrum harder, preventing it from moving freely. That makes it harder to hear properly.

Complications following an acute middle ear infection are very rare. Rare complications include the following:

  • Mastoiditis (bacterial infection of the membranes lining the mastoid bone in the skull, found behind the ear)
  • Meningitis (infection of the membranes covering the brain and spinal cord)
  • Damage to the inner ear (e.g. damage to the nerves, which can lead to hearing loss)

The main symptom of mastoiditis is pain behind the ear, sometimes accompanied by swelling and fever too. Mastoiditis must be treated with antibiotics to prevent the infection from spreading to the bone or from causing meningitis.


Normally the doctor first asks about the acute symptoms and the history of the illness. This is followed by examinations of both ears, the neck and the throat. The doctor also takes the child's temperature.

The eardrum is examined with an instrument called an otoscope. This is a device with a magnifying glass and a small lamp that allows the doctor to look into the ear canal. The doctor can check the child’s hearing with a “tympanometer.” This instrument can generate and pick up noises. It can also change the air pressure to see whether the eardrum is able to move freely.

Three main signs of an acute middle ear infection include

  • sudden onset of the illness with severe earache, fever, hearing problems and general weakness,
  • a red eardrum, and
  • an eardrum that bulges outward, does not move freely and is not transparent, which suggests there might be fluid trapped behind the eardrum.

Sometimes it's not easy to clearly diagnose an acute middle ear infection.


Middle ear infections usually can't be prevented. But doing certain things may possibly lower the risk a bit. One is to give children a pacifier (dummy) less often. It's especially important that the children grow up in a smoke-free environment. Passive smoking increases the risk of infections in the airways, as well as in the upper throat. It also weakens the child's immune system.


Acute middle ear infections can be very painful, so treatment focuses mainly on providing fast pain relief. Medicines that relieve pain and lower fever, such as acetaminophen (paracetamol) or ibuprofen, can be used for this purpose. They are available in the form of suppositories or syrups as well. The problems then typically go away without any further treatment.

Some parents wonder whether their child needs antibiotics. But those are only effective if bacteria have caused the infection. They are ineffective against viruses. If a child has fluid mixed with pus coming out of their ear, or if a child under the age of two has an infection in both ears, it is a sign that the infection is bacterial. In that case antibiotics that a doctor has prescribed can help.

People are often advised to use decongestant nose drops to reduce the swelling and help open up the passages leading to the middle ear. Decongestants probably do not influence the course of the infection or the symptoms, though. If the child’s nose is blocked, nose drops can make it easier for them to breathe through their nose for a few hours. The nose drops should not be used for more than a few days.

Many parents try out home remedies like leg compresses to lower fever or onion wraps to relieve the earache. They haven't been proven to be effective, though. This is also the case for herbal products. Homeopathic products aren't effective.

Further information

When a child is ill and their parents need medical advice, they usually go to see a pediatrician first. In our topic "Health care in Germany" you can read about how to find the right doctor – and our list of questions can help you to prepare for your appointment.


© IQWiG (Institute for Quality and Efficiency in Health Care)
Bookshelf ID: NBK279381


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