Learning Center: EAR INFECTIONS

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Last reviewed: October 2, 2026

Summary

"Ear infection" covers several different problems. The most common is acute otitis media, a bacterial or viral infection behind the eardrum that causes ear pain and fever, usually in a young child after a cold. Most of these infections improve within a few days, with or without antibiotics, so pain control comes first, and many children can be watched for two to three days before an antibiotic is started. Fluid can stay behind the eardrum for weeks to months after an infection (otitis media with effusion, or "ear fluid"). This fluid is not an active infection, usually clears on its own, and does not respond to antibiotics, steroids or decongestants. Swimmer's ear (acute otitis externa) is an infection of the ear canal skin and is treated with ear drops rather than antibiotics by mouth.

Pressure equalization ("PE") tubes are offered when ear fluid lasts three months or more with hearing loss, or when infections keep returning and fluid is present. Removing the adenoids helps some children, mostly those aged four and older or those who need a second set of tubes. Cholesteatoma, mastoiditis and labyrinthitis are less common problems that can follow ear disease and need prompt specialist care.

The sections below explain each of these points in more detail, with the studies behind them. A numbered reference list is at the end of the page. Most of the evidence on this page comes from children, because most ear infections occur in children, and the page says so where the evidence is limited.

Anatomy of the ear

The ear has three parts.

  • The outer ear is the visible ear (the auricle or pinna) and the ear canal. The canal is about an inch long in adults and is lined with thin skin that makes wax. Wax protects the canal and slightly acidifies it, which discourages bacteria and fungus.

  • The middle ear is a small air-filled space behind the eardrum (the tympanic membrane). It holds three tiny bones (the malleus, incus and stapes, together called the ossicles) that carry sound vibrations from the eardrum to the inner ear. Behind and connected to the middle ear is the mastoid, a honeycomb of air cells inside the bone behind the ear.

  • The inner ear is set deep in the skull. It contains the cochlea, which turns vibration into nerve signals for hearing, and the vestibular system (the labyrinth), which senses head movement and supports balance.

The Eustachian tube

The middle ear is connected to the back of the nose (the nasopharynx) by the Eustachian tube. The tube opens briefly with swallowing and yawning. This lets air into the middle ear, keeps the pressure equal on both sides of the eardrum, and lets mucus drain. When the tube does not open well, air in the middle ear is absorbed, pressure drops, and fluid collects. That fluid is a place where bacteria and viruses from the nose can grow.

In young children the Eustachian tube is shorter, floppier and more horizontal than in adults, and the adenoids sit right at its opening in the back of the nose. Colds are frequent in early childhood. Together, these explain why middle ear infections and ear fluid are so common between six months and about three years of age, and why most children outgrow them as the skull grows.

Where each problem occurs

  • Outer ear: swimmer's ear (acute otitis externa).

  • Middle ear: acute otitis media, ear fluid (otitis media with effusion), cholesteatoma.

  • Mastoid: mastoiditis, a spread of middle ear infection into the bone.

  • Inner ear: labyrinthitis.

TYPES OF EAR INFECTIONS

Acute otitis media (middle ear infection)

Acute otitis media (AOM) is an infection of the middle ear that comes on quickly. Fluid behind the eardrum becomes infected, the eardrum bulges, and the ear hurts. Fever, fussiness, poor sleep and tugging at the ear are common in young children. If pressure builds high enough, the eardrum can tear and drain pus, which often relieves the pain. The tear usually heals on its own.

How common it is

AOM is one of the most common illnesses of early childhood. In a Boston cohort followed from birth in the 1980s, 83% of children had at least one episode by age three, and 46% had three or more [1]. Rates have fallen since pneumococcal vaccines were introduced. In a study of children followed after 2006, 23% had an episode by age one and 60% by age three, and 24% had three or more by age three [2]. The peak age is 6 to 12 months [2].

Risk factors

Risk is higher with daycare outside the home, a parent who smokes, a brother, sister or parent with ear infections, and pacifier use. Breastfeeding for at least three months lowers the risk [2, 3]. Boys are affected somewhat more often than girls [2]. Pneumococcal conjugate vaccines, given in infancy, lower the risk of ear infections modestly, and the main benefit is fewer infections caused by the strains in the vaccine [4]. Children with a cleft palate, Down syndrome and some other conditions have a much higher rate of ear disease and are watched more closely [5].

Diagnosis

AOM is diagnosed by looking at the eardrum. The American Academy of Pediatrics guideline requires either moderate to severe bulging of the eardrum, new drainage from the ear not caused by swimmer's ear, or mild bulging with recent ear pain or marked redness of the eardrum [6]. A red eardrum alone, or fluid without bulging, is not enough. This strict definition matters, because fluid without infection (see "Ear fluid" below) is common and does not need antibiotics.

Treatment

Pain control comes first. Acetaminophen or ibuprofen, dosed for the child's weight, is recommended for every child with AOM whether or not an antibiotic is given [6]. Antibiotics do not relieve pain in the first 24 hours [7].

Most infections get better on their own. In a meta-analysis of untreated children, symptoms improved within 24 hours in 61% and within two to three days in 80% [8]. The 2023 Cochrane review of 13 placebo-controlled trials (3,401 children) found that antibiotics:

  • did not reduce pain at 24 hours;

  • reduced the number of children with pain at two to three days by about a third (20 children need to be treated for one to benefit);

  • reduced pain at 10 to 12 days (7 treated for one to benefit, in a single trial);

  • slightly reduced eardrum perforations (33 treated for one to benefit) and halved infections in the other ear (11 treated for one to benefit);

  • caused vomiting, diarrhea or rash in 1 of every 14 children treated [7].

Two placebo-controlled trials in young children, published together in 2011, used the strict diagnostic criteria above. In children aged 6 to 23 months, amoxicillin-clavulanate shortened symptoms and reduced persistent signs of infection on exam at day 10 to 12 from 51% to 16% [9]. In children aged 6 to 35 months, treatment failure fell from 45% with placebo to 19% with antibiotics, at the cost of more diarrhea (48% vs 27%) [10]. The benefit of antibiotics is largest in children under two, children with infection in both ears, and children with drainage from the ear [6, 7].

Watchful waiting. Because of this balance of benefit and harm, the guideline recommends antibiotics right away for children younger than six months, for any child with severe symptoms (moderate to severe pain, pain for 48 hours or more, or a temperature of 39°C [102.2°F] or higher), for children with drainage from the ear, and for children aged 6 to 23 months with infection in both ears. Other children may be observed for 48 to 72 hours, with a plan to start an antibiotic if they do not improve [6]. Some families are given a "wait-and-see" prescription to fill only if needed.

Which antibiotic and for how long. High-dose amoxicillin is the usual first choice unless the child has had amoxicillin in the last 30 days, has conjunctivitis with the ear infection, or is allergic to penicillin [6]. In children under two, a 5-day course failed more often than a 10-day course (34% vs 16%) without fewer side effects, so the full 10-day course is used at that age [11]. Shorter courses (5 to 7 days) are reasonable for older children with milder illness [6].

Complications are rare. In a UK database of more than 2.6 million children, mastoiditis followed 1.8 of every 10,000 ear infections treated with antibiotics and 3.8 of every 10,000 not treated. About 4,800 ear infections would need to be treated to prevent one case [12]. See "Mastoiditis" below.

Recurrent acute otitis media

Recurrent AOM is usually defined as three or more episodes in six months, or four or more in a year with one in the last six months [6]. Even children who meet this definition tend to improve with time. In trials of children entering with five or more infections a year, children on placebo averaged 2.8 infections the following year, 41% had none, and only 17% remained prone to infection [8]. Options include treating each episode as it comes or placing PE tubes (see below). Long-term preventive antibiotics are no longer recommended because of side effects and resistance [6].

Ear infections in adults

AOM is much less common in adults. It usually follows a cold or a flight and is treated much the same way. Adults have the same rare complications as children: in a Finnish series, acute complications of otitis media occurred in about 3 adults per million each year [13]. Fluid that persists in only one ear in an adult is different from a childhood ear infection and is discussed under "Ear fluid" below.

Otitis media with effusion (ear fluid)

Otitis media with effusion (OME) is fluid behind the eardrum without signs of acute infection. It often follows AOM, but it can also come on silently with a cold or allergies. It is discussed in detail in the "Ear fluid" section below.

Acute otitis externa (swimmer's ear)

Acute otitis externa (AOE) is an infection of the skin of the ear canal, usually by bacteria such as Pseudomonas or Staphylococcus. Water that sits in the canal, scratching or cleaning with cotton swabs, hearing aids and earbuds, and skin conditions such as eczema all make it more likely. Symptoms are ear pain that is worse when the outer ear is pulled or pressed, itching, a feeling of fullness, drainage, and muffled hearing from swelling of the canal [14].

The AAO-HNSF guideline makes the following recommendations [14]:

  • Pain should be assessed and treated. AOE can be very painful.

  • Uncomplicated AOE should be treated with antibiotic ear drops, not antibiotics by mouth. Drops deliver a very high dose of antibiotic to the infection with few side effects. Oral antibiotics are reserved for infection that spreads beyond the ear canal or for patients with specific risk factors.

  • If the canal is swollen shut or full of debris, it should be cleaned under the microscope, and a small sponge (a wick) can be placed to carry the drops in.

  • If the eardrum has a hole or a PE tube is present, drops that are safe for the middle ear (such as ofloxacin or ciprofloxacin) should be used.

  • Patients who do not improve within 48 to 72 hours should be re-examined.

A Cochrane review found that antibiotic-steroid drops work much better than placebo, and that the various antibiotic drops work about equally well. Acetic acid drops alone were less effective than antibiotic-steroid drops in one high-quality trial. Most trials were small, and the quality of the evidence was low [15].

People with diabetes, a weakened immune system, or prior radiation to the ear need closer follow-up [14]. In these patients, a rare infection called necrotizing (or "malignant") otitis externa can spread from the canal into the bone of the skull base. It causes severe, persistent pain, often in an older person with diabetes, and needs prompt specialist care and prolonged antibiotics [14].

Preventing swimmer's ear

Drying the ears after swimming, avoiding cotton swabs and other objects in the canal, and leaving normal wax in place are the usual advice. Acidifying drops after swimming are also used by people prone to repeated infections [14].

Pressure equalization ("PE") tubes

PE tubes, also called tympanostomy tubes, ventilation tubes or grommets, are tiny tubes placed through the eardrum. A small opening is made in the eardrum (a myringotomy), the fluid is suctioned out, and the tube is placed in the opening. The tube lets air into the middle ear, keeps the pressure equal, and lets fluid drain out instead of building up. In children the procedure takes about 10 to 15 minutes under a brief general anesthetic. Adults usually have it done in the office with numbing medicine.

Most tubes are "short-term" tubes. They usually stay in for about a year and are pushed out on their own as the eardrum heals behind them. "Long-term" tubes stay longer, but they cause more lasting holes in the eardrum, so they are used only when a long period of ventilation is expected [16, 17].

Who should have tubes

The AAO-HNSF clinical practice guideline on tympanostomy tubes in children (updated in 2022) recommends [16]:

  • Not placing tubes for a single episode of ear fluid that has lasted less than three months.

  • A hearing test when fluid lasts three months or longer, or before surgery.

  • Offering tubes in both ears for fluid in both ears lasting three months or longer with documented hearing difficulty.

  • Considering tubes for fluid lasting three months or longer that causes other problems likely due to the fluid, such as balance problems, poor school performance, behavior problems, ear discomfort or reduced quality of life.

  • Offering tubes for recurrent AOM only if fluid is present in at least one ear at the time of the visit. Tubes are not recommended for recurrent AOM when both ears are clear.

  • Considering tubes earlier for children at higher risk of speech, language or learning problems, such as children with permanent hearing loss, autism, Down syndrome, cleft palate, or developmental delay, when fluid is likely to persist.

What tubes do and do not do

For ear fluid. A meta-analysis found that tubes improved hearing by about 9 decibels at one to three months compared with watchful waiting, but by 12 to 24 months hearing in the two groups was the same [18]. The 2023 Cochrane review reached a similar conclusion: tubes greatly reduce fluid in the first months, but the long-term effect on hearing and development is uncertain [19]. Tubes are therefore most useful when hearing loss is affecting a child now, during a period that matters for speech and learning.

For recurrent infections. The evidence is more mixed. In older trials reviewed by Cochrane, children with tubes had fewer infections in the first six months (an average of 0.67 vs 2.17 episodes per child) and a smaller difference at 12 months (1.15 vs 1.70 episodes) [20]. A 2021 trial of children aged 6 to 35 months with recurrent AOM found no significant difference in the rate of infections over two years between tubes (1.48 per year) and treating each episode with antibiotics (1.56 per year). Children with tubes went longer before their first infection and their infections were milder, but they had more days of ear drainage [21]. This trial is one reason the guideline limits tubes for recurrent AOM to children who also have fluid. When an infection does happen with a tube in place, it usually shows up as drainage rather than pain and can be treated with ear drops instead of antibiotics by mouth [16].

What to expect after tubes

  • Drainage. Drainage through the tube is the most common issue. In a meta-analysis of tube outcomes, drainage occurred in 16% of children shortly after surgery and in 26% at some later time; 7.4% had repeated drainage and 3.8% had long-lasting drainage [17].

  • Treating drainage. For uncomplicated drainage, antibiotic ear drops alone are recommended, without antibiotics by mouth [16]. In a randomized trial of children with tubes and new drainage, 5% of children treated with antibiotic-steroid drops still had drainage at two weeks, compared with 44% treated with oral antibiotics and 55% who were observed. Drainage lasted a median of 4 days with drops, 5 days with oral antibiotics, and 12 days with observation [22].

  • Water. The guideline recommends against routine earplugs, headbands or avoidance of swimming [16]. In a randomized trial, children who swam and bathed without earplugs had slightly more drainage (0.10 vs 0.07 episodes a month), a difference the authors judged too small to justify routine earplugs [23]. Earplugs can still be used for a child who gets drainage after swimming.

  • Follow-up. The ears should be checked within three months of surgery and periodically until the tubes come out [16].

Risks

Most effects of tubes are minor or cosmetic. In the same meta-analysis, tubes became blocked in 7% of ears and fell out early in 3.9%. After the tubes came out, white scarring of the eardrum (tympanosclerosis) was seen in 32% and a thin spot in the eardrum in 25%. These rarely affect hearing. A hole that did not close (a persistent perforation) remained in 2.2% of ears after short-term tubes and 16.6% after long-term tubes, and cholesteatoma developed in 0.7% [17]. A persistent hole can be repaired later if needed. A second set of tubes is needed in a minority of children; the role of the adenoids in this is discussed below.

Role of the adenoids

The adenoids are a pad of lymph tissue at the back of the nose, beside the openings of the Eustachian tubes. They are largest in early childhood and shrink in the teenage years. Enlarged or chronically infected adenoids can block the Eustachian tubes and serve as a reservoir for the bacteria that cause ear infections. Removing them (adenoidectomy) is a short outpatient procedure done through the mouth, with no external incisions.

What the evidence shows

  • For ear fluid. The 2023 Cochrane review of 10 trials (1,785 children) found that adenoidectomy may slightly reduce persistent fluid. At two years, fluid persisted in 65% of children who had adenoidectomy and 73% of those who did not. The effect on hearing was unclear, and the overall certainty of the evidence was low to very low [24].

  • Bleeding risk. The same review found the risk of bleeding after adenoidectomy to be small (3 of 667 children in the trials that reported it) [24].

  • With a first set of tubes. In a meta-analysis of mostly retrospective studies, about 17% of children who had adenoidectomy with their first set of tubes later needed another set, compared with about 32% who had tubes alone. The benefit was smaller in children younger than four [25].

Current recommendations

  • For children younger than four who need surgery for ear fluid, tubes alone are recommended. Adenoidectomy is added only for a separate reason, such as nasal blockage or chronic adenoid infection [5].

  • For children four and older who need surgery for ear fluid, tubes, adenoidectomy or both are reasonable [5].

  • Adenoidectomy may be added to tubes for children with symptoms caused by the adenoids, or for children four and older, to lower the chance of future infections or a second set of tubes [16].

Adenoidectomy is often considered when a child needs a second set of tubes. Large adenoids also cause snoring, mouth breathing and sleep-disordered breathing, which are discussed on the tonsils and adenoids and sleep apnea pages.

Cholesteatoma

A cholesteatoma is a growth of skin in the wrong place: behind the eardrum in the middle ear and mastoid. Despite the name, it has nothing to do with cholesterol and is not a cancer. Skin normally sheds its surface layer outward. When it is trapped in the middle ear, the shed skin (keratin) builds up into a ball. The ball becomes chronically infected and slowly erodes the bone around it [26].

How it forms

Most cholesteatomas are "acquired." They usually start when poor Eustachian tube function creates negative pressure that sucks a weak part of the eardrum inward into a pocket (a retraction pocket). Skin collects in the pocket and cannot clear itself. Less often, skin grows in through a hole in the eardrum or after ear surgery or trauma. A small number are "congenital," present from birth behind an intact eardrum [26]. In a Finnish population study, cholesteatoma was diagnosed in about 9 people per 100,000 each year. Most patients (72%) had a history of ear infections [27]. Cholesteatoma also develops after PE tubes in a small number of ears (0.7% in one meta-analysis) [17].

Symptoms

  • Drainage from one ear, often foul-smelling, that keeps returning despite drops.

  • Gradual hearing loss in that ear as the ossicles are eroded.

  • Less often, dizziness, facial weakness, or the complications of mastoiditis and infection near the brain, when the cholesteatoma erodes into the inner ear, the facial nerve canal, or the bone over the brain.

Cholesteatoma is often painless. Persistent drainage from one ear should be examined under a microscope by an ear specialist.

Diagnosis

The diagnosis is made by examining the ear under the microscope. A hearing test measures the effect on hearing. A CT scan shows the extent of bone erosion and the anatomy for surgery. A special MRI sequence (non-echo planar diffusion-weighted MRI) is very good at detecting cholesteatoma, and it is now used to check for a return of disease after surgery, sometimes in place of a planned second operation [28].

Treatment

Cholesteatoma does not go away with medicine. Ear drops and cleaning can quiet the infection, but the only definitive treatment is surgical removal. The goals, in order, are to remove all of the disease, to leave a safe, dry ear, and to preserve or restore hearing. The operation is usually a tympanomastoidectomy, which removes disease from the middle ear and the mastoid and rebuilds the eardrum. The hearing bones may be rebuilt at the same operation or at a second one.

  • Canal wall up. The bony wall of the ear canal is kept, so the ear looks and works more normally afterward. Because cholesteatoma can hide in the mastoid, a second-look operation or MRI is usually planned about a year later.

  • Canal wall down. The back wall of the canal is removed and the mastoid is opened into the ear canal, creating a "mastoid bowl." This makes it easier to see and clean the area but requires periodic cleaning in the office for life and may limit water exposure.

Cholesteatoma can return either because a few cells were left behind (residual disease) or because a new pocket forms (recurrent disease). In adults, a systematic review found that in most of the included studies disease returned in about 17% to 61% of ears after canal wall up surgery and in 0% to 13% after canal wall down surgery [29]. In children, where disease is often more aggressive, a 2023 meta-analysis of 17 studies (1,333 children) found no significant difference in recurrence or residual disease between the two techniques, and better hearing with canal wall up surgery [30]. Filling the mastoid with bone chips or other material (mastoid obliteration) after canal wall up surgery appears to reduce the return of disease, but the studies so far are retrospective and no randomized trials have been completed [31]. Because the disease can return years later, long-term follow-up is part of treatment.

Mastoiditis

The mastoid air cells connect to the middle ear, so some inflammation of the mastoid is present with almost every middle ear infection and often appears on CT scans. "Acute mastoiditis" refers to a more serious spread of infection into the mastoid bone. It is the most common complication of AOM, but it is uncommon.

How common it is

In a UK database of more than 2.6 million children, mastoiditis occurred at a stable rate of about 1.2 per 10,000 children each year. Only about a third of the children who developed mastoiditis had seen their doctor for an ear infection beforehand. Antibiotics halved the risk of mastoiditis after an ear infection (1.8 vs 3.8 per 10,000 episodes), but about 4,800 ear infections would need to be treated to prevent one case [12]. This is one reason careful watchful waiting is considered safe for many children with AOM.

Symptoms

  • Redness, swelling and tenderness of the skin behind the ear.

  • The ear pushed forward and outward.

  • Fever, ear pain, and often a bulging eardrum or drainage.

  • Worsening symptoms despite antibiotics.

Mastoiditis can lead to a collection of pus under the skin behind the ear (a subperiosteal abscess), weakness of the face, labyrinthitis, and rarely infection inside the skull, such as meningitis, brain abscess, or a clot in the large vein next to the mastoid (sigmoid sinus thrombosis) [13]. Severe headache, stiff neck, drowsiness, weakness of the face, or vomiting with severe dizziness should be evaluated right away.

Treatment

Children and adults with acute mastoiditis are usually admitted for intravenous antibiotics. A CT or MRI scan is obtained when an abscess or a complication inside the skull is suspected. In uncomplicated cases, treatment has moved toward less surgery. A systematic review of 21 studies (564 children) found cure rates of 96% with medical treatment alone, 96% with limited surgery (such as myringotomy, with or without a PE tube), and 89% with mastoidectomy. The authors concluded that conservative treatment is an appropriate first step in uncomplicated cases [32]. Mastoidectomy is reserved for cases that do not improve, for abscesses or complications inside the skull, and for mastoiditis caused by an underlying cholesteatoma.

Labyrinthitis

Labyrinthitis is inflammation of the inner ear. Because the inner ear controls both hearing and balance, labyrinthitis causes sudden, severe spinning dizziness (vertigo) with nausea and vomiting, together with hearing loss and often ringing (tinnitus) in the affected ear. When the same kind of inflammation affects only the balance nerve, with normal hearing, it is called vestibular neuritis. The two are often grouped together.

Causes

  • Viral (the most common). Most cases are thought to be caused by a virus or the body's response to one, often after a cold. Herpes simplex virus has been proposed as one cause of vestibular neuritis, though antiviral medicine has not proven helpful [33].

  • Bacterial (rare). A middle ear infection, mastoiditis, cholesteatoma, or meningitis can spread into the inner ear. This is an intratemporal complication of ear infection that can cause permanent hearing loss and needs urgent treatment of the underlying ear disease [13, 34].

Symptoms and course

Vertigo usually begins suddenly, is worst in the first one to three days, and then gradually improves over days to weeks as the brain adapts. A feeling of imbalance with quick head movements can last weeks to months. Hearing loss from viral labyrinthitis may recover partly or fully. Sudden vertigo is not always from the ear. New trouble speaking, double vision, weakness, numbness, or inability to walk, especially in an older adult or someone with stroke risk factors, should be evaluated as an emergency to exclude a stroke.

Treatment

  • Short-term symptom relief. Medicines for nausea and vertigo help in the first few days. They are usually used only for a short time, while the brain adapts.

  • Steroids. The evidence is mixed. A 2004 trial found that methylprednisolone improved recovery of balance function on testing at 12 months (62 vs 40 percentage points), while the antiviral valacyclovir had no benefit [33]. A 2011 Cochrane review of four small trials found better recovery on balance testing at one month but not at 12 months, and no clear improvement in symptoms [35]. A 2021 meta-analysis in adults reached a similar conclusion [36]. A 2022 meta-analysis of 15 trials found a benefit for steroids but more side effects, and noted that most studies were of low quality [37]. Steroids are therefore considered case by case, mainly early in the illness.

  • Vestibular rehabilitation. Specific exercises guided by a physical therapist help the brain compensate for the injured inner ear. A Cochrane review of 39 trials found moderate to strong evidence that vestibular rehabilitation is safe and effective for this kind of inner ear injury [38].

  • Bacterial labyrinthitis is treated with antibiotics and treatment of the source, such as a PE tube for a middle ear infection or surgery for cholesteatoma [34].

Ear fluid (otitis media with effusion)

Otitis media with effusion (OME), often called "glue ear," is fluid in the middle ear without signs of acute infection. There is usually no pain or fever. The main effect is a mild to moderate hearing loss in the affected ear, like listening with a finger in the ear. Young children may turn up the television, seem inattentive, speak less clearly, or have balance problems. Many children have no obvious symptoms at all, and the fluid is found at a routine visit [5].

OME is extremely common. About 90% of children have it at some point before school age, most often between six months and four years [5].

Diagnosis

The guideline recommends confirming fluid with pneumatic otoscopy, in which a puff of air is used to see whether the eardrum moves. Tympanometry, a quick test of how the eardrum moves with pressure, is used when the exam is uncertain. A hearing test is recommended when fluid has lasted three months or longer [5].

Natural history

Most ear fluid goes away on its own. After an untreated ear infection, the fluid cleared in 59% of children by one month and 74% by three months. Fluid of unknown duration cleared in 28% by three months and 42% by six months. Fluid that has already lasted three months or more is slower to clear: 26% by six months and 33% by one year [8].

Treatment

Watchful waiting. For children who are not at special risk, the guideline recommends watching for three months from the start of the fluid (or from diagnosis if the start is unknown), with recheck visits every three to six months while it persists [5].

What does not help. The guideline makes strong recommendations against treating OME with steroids (by mouth or nasal spray), antibiotics, antihistamines or decongestants [5]. The evidence behind this:

  • In the OSTRICH trial of 389 children aged 2 to 8 with persistent fluid and hearing loss, a week of oral prednisolone did not meaningfully improve hearing at five weeks (40% vs 33% with acceptable hearing, not significant) [39]. A 2023 Cochrane review found that oral steroids probably make little or no difference to hearing at 12 months [40].

  • A 2023 Cochrane review of antibiotics found at most a small, uncertain effect on persistent fluid, against the known side effects of antibiotics [41].

Autoinflation. Autoinflation means blowing up a special balloon with the nose, which pushes air up the Eustachian tube. In a randomized trial of 320 children aged 4 to 11, those using the balloon were more likely to have normal tympanometry at three months (50% vs 38%) and had better ear-related quality of life [42]. It is safe and inexpensive but requires a child old enough to do it reliably several times a day.

Hearing support. While waiting, simple steps help: face the child when speaking, reduce background noise, and seat the child near the teacher. For a child with a significant hearing loss from long-standing fluid, PE tubes are offered, as described above [5, 16].

Children at higher risk

Some children are more likely to have speech, language or learning problems from ear fluid, including children with permanent hearing loss, speech or language delay, autism, Down syndrome or other syndromes affecting the face, cleft palate, blindness, or developmental delay. These children are evaluated for fluid early, and earlier treatment is considered [5].

Ear fluid in adults

Ear fluid is less common in adults. It often follows a cold or a flight and clears over weeks. Fluid that persists in one ear in an adult, without a clear cause, should prompt an examination of the back of the nose (the nasopharynx) with a small scope, because a tumor there can block the Eustachian tube. In a systematic review of adults with isolated fluid of unknown cause, 5.5% were found to have a malignant tumor in the nasopharynx [43]. This is uncommon, but it is the reason a persistent one-sided ear fluid in an adult is not simply observed.

For more on ear fluid and how it differs from infection:

Related pages

References

  1. Teele DW, Klein JO, Rosner B. Epidemiology of otitis media during the first seven years of life in children in greater Boston: a prospective, cohort study. J Infect Dis. 1989;160(1):83-94. doi:10.1093/infdis/160.1.83

  2. Kaur R, Morris M, Pichichero ME. Epidemiology of acute otitis media in the postpneumococcal conjugate vaccine era. Pediatrics. 2017;140(3):e20170181. doi:10.1542/peds.2017-0181

  3. Uhari M, Mäntysaari K, Niemelä M. A meta-analytic review of the risk factors for acute otitis media. Clin Infect Dis. 1996;22(6):1079-1083. doi:10.1093/clinids/22.6.1079

  4. Fortanier AC, Venekamp RP, Boonacker CW, et al. Pneumococcal conjugate vaccines for preventing acute otitis media in children. Cochrane Database Syst Rev. 2019;5(5):CD001480. doi:10.1002/14651858.CD001480.pub5

  5. Rosenfeld RM, Shin JJ, Schwartz SR, et al. Clinical practice guideline: otitis media with effusion (update). Otolaryngol Head Neck Surg. 2016;154(1 Suppl):S1-S41. doi:10.1177/0194599815623467

  6. Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diagnosis and management of acute otitis media. Pediatrics. 2013;131(3):e964-e999. doi:10.1542/peds.2012-3488

  7. Venekamp RP, Sanders SL, Glasziou PP, et al. Antibiotics for acute otitis media in children. Cochrane Database Syst Rev. 2023;11(11):CD000219. doi:10.1002/14651858.CD000219.pub5

  8. Rosenfeld RM, Kay D. Natural history of untreated otitis media. Laryngoscope. 2003;113(10):1645-1657. doi:10.1097/00005537-200310000-00004

  9. Hoberman A, Paradise JL, Rockette HE, et al. Treatment of acute otitis media in children under 2 years of age. N Engl J Med. 2011;364(2):105-115. doi:10.1056/NEJMoa0912254

  10. Tähtinen PA, Laine MK, Huovinen P, et al. A placebo-controlled trial of antimicrobial treatment for acute otitis media. N Engl J Med. 2011;364(2):116-126. doi:10.1056/NEJMoa1007174

  11. Hoberman A, Paradise JL, Rockette HE, et al. Shortened antimicrobial treatment for acute otitis media in young children. N Engl J Med. 2016;375(25):2446-2456. doi:10.1056/NEJMoa1606043

  12. Thompson PL, Gilbert RE, Long PF, et al. Effect of antibiotics for otitis media on mastoiditis in children: a retrospective cohort study using the United Kingdom general practice research database. Pediatrics. 2009;123(2):424-430. doi:10.1542/peds.2007-3349

  13. Leskinen K, Jero J. Acute complications of otitis media in adults. Clin Otolaryngol. 2005;30(6):511-516. doi:10.1111/j.1749-4486.2005.01085.x

  14. Rosenfeld RM, Schwartz SR, Cannon CR, et al. Clinical practice guideline: acute otitis externa. Otolaryngol Head Neck Surg. 2014;150(1 Suppl):S1-S24. doi:10.1177/0194599813517083

  15. Kaushik V, Malik T, Saeed SR. Interventions for acute otitis externa. Cochrane Database Syst Rev. 2010;(1):CD004740. doi:10.1002/14651858.CD004740.pub2

  16. Rosenfeld RM, Tunkel DE, Schwartz SR, et al. Clinical practice guideline: tympanostomy tubes in children (update). Otolaryngol Head Neck Surg. 2022;166(1 Suppl):S1-S55. doi:10.1177/01945998211065662

  17. Kay DJ, Nelson M, Rosenfeld RM. Meta-analysis of tympanostomy tube sequelae. Otolaryngol Head Neck Surg. 2001;124(4):374-380. doi:10.1067/mhn.2001.113941

  18. Steele DW, Adam GP, Di M, et al. Effectiveness of tympanostomy tubes for otitis media: a meta-analysis. Pediatrics. 2017;139(6):e20170125. doi:10.1542/peds.2017-0125

  19. MacKeith S, Mulvaney CA, Galbraith K, et al. Ventilation tubes (grommets) for otitis media with effusion (OME) in children. Cochrane Database Syst Rev. 2023;11(11):CD015215. doi:10.1002/14651858.CD015215.pub2

  20. Venekamp RP, Mick P, Schilder AG, et al. Grommets (ventilation tubes) for recurrent acute otitis media in children. Cochrane Database Syst Rev. 2018;5(5):CD012017. doi:10.1002/14651858.CD012017.pub2

  21. Hoberman A, Preciado D, Paradise JL, et al. Tympanostomy tubes or medical management for recurrent acute otitis media. N Engl J Med. 2021;384(19):1789-1799. doi:10.1056/NEJMoa2027278

  22. van Dongen TM, van der Heijden GJ, Venekamp RP, et al. A trial of treatment for acute otorrhea in children with tympanostomy tubes. N Engl J Med. 2014;370(8):723-733. doi:10.1056/NEJMoa1301630

  23. Goldstein NA, Mandel EM, Kurs-Lasky M, et al. Water precautions and tympanostomy tubes: a randomized, controlled trial. Laryngoscope. 2005;115(2):324-330. doi:10.1097/01.mlg.0000154742.33067.fb

  24. MacKeith S, Mulvaney CA, Galbraith K, et al. Adenoidectomy for otitis media with effusion (OME) in children. Cochrane Database Syst Rev. 2023;10(10):CD015252. doi:10.1002/14651858.CD015252.pub2

  25. Mikals SJ, Brigger MT. Adenoidectomy as an adjuvant to primary tympanostomy tube placement: a systematic review and meta-analysis. JAMA Otolaryngol Head Neck Surg. 2014;140(2):95-101. doi:10.1001/jamaoto.2013.5842

  26. Yung M, Tono T, Olszewska E, et al. EAONO/JOS joint consensus statements on the definitions, classification and staging of middle ear cholesteatoma. J Int Adv Otol. 2017;13(1):1-8. doi:10.5152/iao.2017.3363

  27. Kemppainen HO, Puhakka HJ, Laippala PJ, et al. Epidemiology and aetiology of middle ear cholesteatoma. Acta Otolaryngol. 1999;119(5):568-572. doi:10.1080/00016489950180801

  28. van Egmond SL, Stegeman I, Grolman W, et al. A systematic review of non-echo planar diffusion-weighted magnetic resonance imaging for detection of primary and postoperative cholesteatoma. Otolaryngol Head Neck Surg. 2016;154(2):233-240. doi:10.1177/0194599815613073

  29. Kerckhoffs KG, Kommer MB, van Strien TH, et al. The disease recurrence rate after the canal wall up or canal wall down technique in adults. Laryngoscope. 2016;126(4):980-987. doi:10.1002/lary.25591

  30. Solis-Pazmino P, Siepmann T, Scheffler P, et al. Canal wall up versus canal wall down mastoidectomy techniques in the pediatric population with cholesteatoma: a systematic review and meta-analysis of comparative studies. Int J Pediatr Otorhinolaryngol. 2023;173:111658. doi:10.1016/j.ijporl.2023.111658

  31. Erfurt C, de Rooij MJ, Straatman LV, et al. Mastoid obliteration in addition to the canal wall up tympanomastoidectomy: a systematic review. Otol Neurotol. 2026 (online ahead of print). doi:10.1097/MAO.0000000000005075

  32. Loh R, Phua M, Shaw CL. Management of paediatric acute mastoiditis: systematic review. J Laryngol Otol. 2018;132(2):96-104. doi:10.1017/S0022215117001840

  33. Strupp M, Zingler VC, Arbusow V, et al. Methylprednisolone, valacyclovir, or the combination for vestibular neuritis. N Engl J Med. 2004;351(4):354-361. doi:10.1056/NEJMoa033280

  34. Kitsko DJ, Dohar JE. Inner ear and facial nerve complications of acute otitis media, including vertigo. Curr Allergy Asthma Rep. 2007;7(6):444-450. doi:10.1007/s11882-007-0068-1

  35. Fishman JM, Burgess C, Waddell A. Corticosteroids for the treatment of idiopathic acute vestibular dysfunction (vestibular neuritis). Cochrane Database Syst Rev. 2011;(5):CD008607. doi:10.1002/14651858.CD008607.pub2

  36. Leong KJ, Lau T, Stewart V, et al. Systematic review and meta-analysis: effectiveness of corticosteroids in treating adults with acute vestibular neuritis. Otolaryngol Head Neck Surg. 2021;165(2):255-266. doi:10.1177/0194599820982910

  37. Bogdanova A, Dlugaiczyk J, Heckmann JG, et al. Corticosteroids in patients with vestibular neuritis: an updated meta-analysis. Acta Neurol Scand. 2022;146(5):429-439. doi:10.1111/ane.13676

  38. McDonnell MN, Hillier SL. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database Syst Rev. 2015;1(1):CD005397. doi:10.1002/14651858.CD005397.pub4

  39. Francis NA, Cannings-John R, Waldron CA, et al. Oral steroids for resolution of otitis media with effusion in children (OSTRICH): a double-blinded, placebo-controlled randomised trial. Lancet. 2018;392(10147):557-568. doi:10.1016/S0140-6736(18)31490-9

  40. Mulvaney CA, Galbraith K, Webster KE, et al. Topical and oral steroids for otitis media with effusion (OME) in children. Cochrane Database Syst Rev. 2023;12(12):CD015255. doi:10.1002/14651858.CD015255.pub2

  41. Mulvaney CA, Galbraith K, Webster KE, et al. Antibiotics for otitis media with effusion (OME) in children. Cochrane Database Syst Rev. 2023;10(10):CD015254. doi:10.1002/14651858.CD015254.pub2

  42. Williamson I, Vennik J, Harnden A, et al. Effect of nasal balloon autoinflation in children with otitis media with effusion in primary care: an open randomized controlled trial. CMAJ. 2015;187(13):961-969. doi:10.1503/cmaj.141608

  43. Rohde M, Korsholm M, Lüscher M, et al. Diagnosis of possible nasopharyngeal malignancy in adults with isolated serous otitis media; a systematic review and proposal of a management algorithm. Eur Arch Otorhinolaryngol. 2022;279(7):3229-3235. doi:10.1007/s00405-022-07279-w

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