Middle ear infection: symptoms, treatment and when antibiotics are needed

At a glance

What is it? An acute inflammation of the middle ear (acute otitis media), often following a cold. It is painful but usually heals well.

Main symptom Sudden, severe earache, in children often together with fever and restlessness.

Who is affected? Mainly young children between six months and three years. In adults it is much less common.

Important About 80 percent heal without antibiotics. Watchful waiting with good pain relief is often the right first step.

What is a middle ear infection?

In acute otitis media, the air-filled space behind the eardrum becomes inflamed. The trigger is usually a cold: the mucous membranes swell, the Eustachian tube that connects the middle ear to the throat gets blocked, and secretions can no longer drain. Viruses or bacteria multiply in these secretions, the middle ear becomes inflamed, and pressure builds against the eardrum. It is this pressure that causes the typical, often very severe pain.

It is important to distinguish this from a so-called middle ear effusion (glue ear). Here, fluid collects behind the eardrum without an acute, painful infection. An effusion mainly causes muffled hearing and needs different care from the acute infection.

There is an anatomical reason why young children are mostly affected: their Eustachian tube is shorter, narrower and runs flatter than in adults. Secretions drain less well, and pathogens reach the middle ear more easily. By school age, roughly every second to third child has had at least one middle ear infection.

Keep a close eye on the first few days

With watchful waiting in particular, it matters to follow fever, pain and general condition over time. With brite you record symptoms and temperature free of charge and notice sooner when a doctor visit is needed.

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Symptoms: how do I recognise a middle ear infection?

The main symptom is sudden, often throbbing earache. Other complaints frequently occur alongside it:

Fever, especially in children, often between 38 and 39 degrees
Muffled hearing or a feeling of pressure in the ear
Tiredness, loss of appetite and disturbed sleep
Sometimes dizziness or a ringing in the ear

If fluid or pus leaks from the ear, the eardrum has usually torn under the pressure. That sounds dramatic, but it often relieves the pain suddenly, and the tear normally heals on its own. Even so, any such discharge should be checked by a doctor.

In babies and toddlers who cannot yet name their complaints, a middle ear infection often shows only indirectly: through fussiness, frequent grabbing or rubbing of the ear, crying when lying down, poor feeding and fever. Taking these signs seriously is the first step toward the right assessment.

Child or adult: the key differences

A middle ear infection does not run the same way in children and adults, and that affects how the complaints are assessed.

Feature	In children	In adults
Frequency	Very common, especially from six months to three years	Much less common
Why susceptible	Short, flat Eustachian tube and frequent colds	Usually following a respiratory infection, rarely anatomical
Typical signs	Often indirect: fussiness, grabbing the ear, fever, poor feeding	Clearly localised earache, pressure, reduced hearing
Special note	Under six months, always seek medical care	Have one-sided, persistent complaints checked by a doctor

One point in adults deserves special attention: a repeatedly one-sided or stubborn middle ear infection should be examined more closely by a doctor to rule out rare causes in the nose and throat area. In children, by contrast, the acute infection is usually a harmless side effect of colds.

Watchful waiting: why not every middle ear infection needs antibiotics

For a long time, antibiotics were the standard. Today the recommendation from medical societies is different, and for good reason: about 80 percent of uncomplicated middle ear infections heal under pain treatment on their own, often because viruses are the cause, against which antibiotics do not work anyway. Studies also show that antibiotics do not relieve pain in the first 24 hours and make only a small difference afterwards.

This limited benefit comes with real downsides. About one in 14 treated children develops side effects from the antibiotic, such as diarrhoea, vomiting or a rash. Frequent use also promotes resistance, and in children early antibiotics can increase the risk of repeat infections.

The preferred approach is therefore watchful waiting. In concrete terms this means:

Treat pain consistently: Adequate pain relief with paracetamol or ibuprofen in an age-appropriate dose is the most important step.
Observe for 24 to 48 hours: If the condition improves within this window, antibiotics are usually not needed.
A prescription in your pocket: Some doctors issue a prescription that is only filled if there is no improvement. This avoids many unnecessary antibiotics.

When are antibiotics needed?

Watchful waiting applies to the uncomplicated course. In certain situations, antibiotic treatment from the start is sensible or necessary:

Infants under six months, where treatment is given as a rule
Severe symptoms such as high fever, intense pain or a clearly reduced general condition
Fluid or pus leaking from the ear
A middle ear infection on both sides in toddlers under two years
Certain risk factors, such as a weakened immune system or frequently recurring infections
No improvement or a worsening after 48 to 72 hours

If an antibiotic is indicated, amoxicillin is usually the first choice. It is normally taken for seven to ten days. It is important to complete the prescribed course and not to stop as soon as the pain is gone, as this helps prevent relapses and resistance. For a penicillin allergy or recurring infections, the doctor chooses a suitable alternative.

Finish the antibiotic course properly

If an antibiotic is prescribed, taking it regularly for the full course is what counts. brite reminds you of every dose and automatically checks for interactions with other medicines, for you or your child.

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Warning signs for parents: see a doctor immediately

Most middle ear infections are harmless. With these signs, however, you should not wait but seek medical help right away, in an emergency via 112: redness, swelling or tenderness behind the ear (a sign of mastoiditis), a stiff neck or severe headache, a drooping corner of the mouth or facial weakness, persistent vomiting, a very listless or seriously ill child, and any fever in an infant under six months.

How to support healing

Alongside pain treatment, you can support the course with simple measures:

Drink plenty of fluids to help loosen secretions and support recovery
Sleep with the head slightly raised, which lowers the pressure in the ear
Offer warmth or cooling at the ear, whichever feels more pleasant
Do not use cotton swabs or ear drops without medical advice, especially with a damaged eardrum

Frequently asked questions about middle ear infection

The worst pain usually eases after two to three days, and the infection normally heals within a week. About 80 percent of children recover on their own, even without an antibiotic.

No. Most uncomplicated middle ear infections heal under pain treatment on their own. Antibiotics are only needed in certain cases, such as infants under six months, severe symptoms or a lack of improvement.

The first choice is usually amoxicillin, a penicillin antibiotic. For a penicillin allergy or repeated infections, alternatives are considered. The doctor makes the decision.

Always for infants under six months, and also with high fever, severe pain, fluid from the ear, or if nothing improves after two to three days. Swelling or redness behind the ear is an emergency.

The infection itself is not passed directly from person to person. The cold viruses that often precede it, however, are contagious.

The most important step is adequate pain relief, for example with paracetamol or ibuprofen in an age-appropriate dose. Rest and a comfortable, slightly raised head position can ease things further.

With an acute infection, equalising pressure when flying can be very painful. So have a planned flight checked by a doctor beforehand.

Yes. In most cases a middle ear infection heals on its own within a few days under good pain treatment, without an antibiotic.

Track symptoms and stay on top of medication

Whether watchful waiting or an antibiotic: with brite you keep the overview, for you and your family.

✓Document fever, pain and progress and spot warning signs earlier
✓Intake reminders so an antibiotic is reliably finished
✓Interaction check for all medicines in one place
✓Free, ad-free and GDPR-compliant on servers in Germany

Sources

DEGAM: S2k guideline Earache, AWMF register 053-009 (2014, under revision).
DGHNO-KHC: S2k guideline Antibiotic therapy of head and neck infections, AWMF register 017-066.
Venekamp RP et al.: Antibiotics for acute otitis media in children, Cochrane Database of Systematic Reviews, 2023.
MSD Manual, Professional edition: Acute otitis media (2025).

This article is for general information only and does not replace medical advice, diagnosis or treatment. For severe symptoms, for children under six months or for warning signs, please seek medical care at a practice or clinic, and in an emergency call 112. Take medicines only after medical advice and at the appropriate dose.