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Ear Infection


Ear infections can be classified on the basis of the part of the ear affected:

  1. Otitis externa (OE) - infection of the outer ear
  2. Otitis media (OM)- infection of the middle ear
Ear anatomy

Otitis externa


OE is classified by the following criteria:

Infections can be bacterial, viral or fungal. Some of the most common of these are shown in the table below.

Infections can be bacteria, viral or fungal. Some of the most common of these are shown below.

Who gets OE?


Factors that predispose to OE are:

  • Swimming
  • Hearing aids
  • Ear canal abnormalities
  • Skin conditions such as eczema and psoriasis
  • Diabetes
  • Trauma 





The most common symptom is pain. This is made worse by moving the pinna and the patient may be reluctant to being examined with the otoscope.

! NOTE: This differentiates OE from OM which does not cause pain on palpation.

Other symptoms are itch, discharge and irritation of the outer ear, particularly in fungal infections and there may be temporary conductive hearing loss if the canal becomes blocked.



On examination of the outer ear the canal may contain a scanty watery discharge and debris. 

Cleaning the ear canal may reveal erythematous, oedematous walls and if severe narrowing of the canal.


! NOTE: Unlike the middle ear, the external ear does not have any mucus glands, therefore if a thick mucus discharge is seen this would be more indicative of middle ear pathology.  



! NOTE: Culture of the drainage is usually only performed in cases resistant to treatment.

Typical treatment:

  • Analgesics
  • Aural toilet (by using a small suction machine)
  • Ear drops such as Sofradex or Gentisone HC
  • Ear Spray (Otomize) can also be given 

    ! NOTE: Systemic antibiotics are generally not useful 

    ! NOTE: Very important to avoid the use of cotton buds and prevent water getting into the ear

    ! NOTE: Resistant or recurrent cases need to be referred to ENT or dermatology for further investigation.  

    Acute otitis media


    AOM is defined as infection of the middle ear

    Who gets AOM?

    AOM is common in young children. Most children will have at least one episode of AOM. This is most common at 6-12 months of age. Infants and young children are prone to OM because their Eustachian tubes are short, horizontal and poorly functioning. 

    Factors that predispose to AOM are:

    • Upper respiratorys tract infections (which often preceed AOM)
    • Glue ear
    • Passive smoking
    • Bottle feeding




    The main symptom is pain.

    In young children this may present as an irritable child pulling at their ear.

    The child may also be unwell with nausea and vomiting.

    The diagram shows the series of events and the associated symptoms commonly seen in AOM. 

    In adults the presenting symptom may be deafness +/- tinnitus.

    ! NOTE: Every child with a fever must have their tympanic membranes examined 


    • Fever
    • On examination the tympanic membrane may be red, tense and bulging or it may have perforated expelling mucopurulent discharge into the ear canal.


    • 80% resolve spontaneously 
    • Analgesics
    • Antibiotics (Amoxicillin is widely used) shorten the duration of pain but have not been shown to reduce the risk of hearing loss


    !NOTE: Many cases of AOM are caused by viral infections and will resolve on their own within 2-3 days. There is a body of opinion that clinicians should not jump to prescribing antibiotics if they are able to follow up the child such as in a GP setting. Antibiotics are usually given when the child cannot be followed up and in severe or unresolving cases. It is often useful to give the parents a prescription, but ask them to only use it if their child remains unwell after 2-3 days. 

    !NOTE: Neither decongestants nor antihistamines are beneficial. 


    Recurrent ear infections can lead to otitis media with effusion (glue ear). This is asymptomatic apart from possible reduced hearing. On examination the tympanic membrane is dull and retracted and in many cases a fluid level is present. This condition usually resolves spontaneously, with antibiotics giving no long term benefit. If this condition interferes with normal speech development and learning difficulties, grommets and adenoidectomy are considered. 

    AOM if left untreated can result in serious complications such as the following:

    • Acute mastoiditis
    • Facial nerve palsy
    • Meningitis
    • Brain, extra dural or sub dural abscess
    • Venous sinus thrombosis

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