Middle ear infection (otitis media)
Also called: otitis media, acute otitis media, AOM, ear infection, middle ear infection, earache in children
Otitis media is an infection of the middle ear, the space behind the eardrum. It is very common in young children and often follows a cold. It causes ear pain and fever, and most children get better within about three days without antibiotics. Pain relief is the main treatment.
General health information for Pakistan. It does not give doses or brand advice. If you are worried, or symptoms are severe, see a doctor. When to see a doctor
Overview
Otitis media is an infection of the middle ear. The middle ear is the small air-filled space behind the eardrum. When it is infected, fluid builds up behind the eardrum and presses on it, which causes pain. Ear infections are very common, especially in babies and young children, and they often start after a cold or flu.
The infection can be caused by a virus or by bacteria. In most children it settles on its own. Symptoms usually last about three days, but they can last up to a week. Serious problems are rare. Antibiotics only help a little: they ease pain slightly after a couple of days, and they do not prevent hearing loss. For this reason, UK and US guidelines advise that many children do not need an antibiotic straight away. Pain relief with paracetamol or ibuprofen is the most important treatment.
A doctor is more likely to give an antibiotic to a child under 2 years old with infection in both ears, to anyone with pus or fluid coming out of the ear (otorrhoea), to a child with severe symptoms, or to someone who is very unwell or at high risk of complications. Sometimes the doctor gives a 'back-up' prescription to use only if the child is not better after three days or gets worse.
If fluid stays behind the eardrum after the infection has gone, without pain or fever, this is called glue ear (otitis media with effusion). Ear discharge that goes on for a long time is called chronic suppurative otitis media.
In Pakistan: what studies show
Pakistan has only small local studies. In one Mardan town, 10.3% of school children had long-lasting ear infection, and at one Hyderabad hospital Pseudomonas was found in 50.50% of pus samples from such ears, often resistant to common antibiotics.
- A 2018 study in schools of one town in Mardan found that 10.3% of 184 school children had chronic (long-lasting) otitis media.[1] (cross-sectional, data 1 Apr 2018 - 30 Apr 2018)
- Among 328 young children with hearing problems seen at three health facilities in Bahawalpur in 2020-2021, glue ear (otitis media with effusion) was the most common cause, in 27.1%.[2] (cross-sectional, data Sep 2020 - Mar 2021)
- Among 788 children seen with ear problems at two hospitals in Karachi in 2019-2023, 19.29% had chronic suppurative otitis media (long-lasting ear discharge).[3] (cross-sectional, data 2019-2023)
- In one military hospital in Hyderabad (2023-2024), the germ Pseudomonas aeruginosa was found in 50.50% of ear samples from patients with chronic suppurative otitis media.[4] (cross-sectional, data May 2023 - May 2024)
- In the same Hyderabad hospital study, MRSA (a Staph aureus germ that resists many common antibiotics) was found in 10.89% of ear samples.[4] (cross-sectional, data May 2023 - May 2024)
- One hospital study of 98 children in Larkana found Staph aureus was the most common germ in ear discharge from chronic ear infection, in 21.4% of samples.[5] (cross-sectional, data not stated)
- In the same Larkana study, Pseudomonas from children's ears showed 75-81% resistance to two commonly used antibiotics, ceftazidime and gentamicin.[5] (cross-sectional, data not stated)
- At the ear, nose and throat clinic of one Lahore hospital in late 2021, acute suppurative otitis media was the reason for 32.9% of the antibiotic prescriptions studied, second only to sore throat.[6] (prescription review, data 1 Oct 2021 - 31 Dec 2021)
What we do not know yet: There is no national survey of ear infections or the hearing loss they cause in Pakistan; all data come from single schools or hospitals, and no Pakistan guideline on otitis media was found. Studies disagree on the commonest germ: Pseudomonas led in Hyderabad (50.50%) but Staph aureus led in Larkana (21.4%), so ear swab testing matters.
Pakistan studies cited
- Imad, Afridi A, Mehmood T Prevalence of Chronic Otitis Media in School Children of Sheikh Maltoon Town Mardan. Journal of Bacha Khan Medical College 2022;3(1):36-39. doi:10.69830/jbkmc.v3i01.26. Open source
- Ali S, Khan MSG, Zahid L Common causes of hearing impairment among children less than 8 years of age in District Bahawalpur, Punjab Pakistan. Journal of the Pakistan Medical Association 2022;72(8):1544-1546. doi:10.47391/JPMA.3879. Open source
- Feroz S, Rehman EU, Raza MS, et al. Patterns of Ear Morbidities Among Pediatric Age Group: A Tertiary Care Hospital-Based Study. Cureus 2025;17(5):e83958. doi:10.7759/cureus.83958. Open source
- Iftikhar M, Akbar F Evaluation of Causative Microorganisms and their Antibiotic Sensitivity Patterns in Chronic Suppurative Otitis Media at Combined Military Hospital, Hyderabad, Sindh. Pakistan Armed Forces Medical Journal 2026;76(Suppl-8):S1261-S1265. doi:10.51253/pafmj.v76iSUPPL-8.13672. Open source
- Shaikh SH, Hingoro A, Parkash O, et al. Chronic suppurative otitis media: Prevalence and antibiotic resistance pattern of bacterial isolates. Rawal Medical Journal 2025;50(4):973-976. Open source
- Sajjad U, Afzal N, Asif M, et al. Evaluation of antibiotic prescription patterns using WHO AWaRe classification. Eastern Mediterranean Health Journal (WHO EMRO) 2024;30(2):156-162. doi:10.26719/emhj.24.031. Open source
Symptoms
- Ear pain (earache)
- Fever (high temperature)
- Reduced hearing in the affected ear
- A feeling of fullness or pressure in the ear
- Fluid or pus coming out of the ear (discharge), which can happen if the eardrum bursts
- In babies and young children: rubbing or pulling at the ear
- In babies and young children: crying, irritability, restlessness or poor sleep
- In babies and young children: eating or feeding less than usual
- In babies and young children: not reacting to some sounds, or seeming unsteady and losing balance
Causes and risk factors
Causes
- Viruses, often the same ones that cause colds and flu
- Bacteria, which can infect the middle ear on their own or after a virus
- A recent cold, flu or other infection of the nose and throat, which often comes before an ear infection
What makes it more likely
- Being a baby or young child, as ear infections are most common in this age group
- Colds, flu and other infections of the nose and throat
- Breathing in tobacco smoke at home or elsewhere
- Not being breastfed; guidelines encourage breastfeeding only (no other milk or food) for at least the first 6 months
- Using a dummy (pacifier) after 6 months of age
- Missing childhood vaccines, including the pneumococcal vaccine and the yearly flu vaccine
- Long-term heart, lung, kidney, liver or nerve-and-muscle disease, a weak immune system, cystic fibrosis or being born early (premature), which raise the risk of complications
Complications
Most ear infections clear up without lasting problems. The eardrum can tear (perforate), which lets pus drain out of the ear. Fluid can stay behind the eardrum after the infection has gone (glue ear) and can dull hearing for a while. Ear discharge that goes on for a long time is called chronic suppurative otitis media and needs a doctor's care. Rarely, the infection spreads to nearby areas. These serious complications include infection of the bone behind the ear (mastoiditis), meningitis (infection of the covering of the brain), a collection of pus inside the skull (brain abscess), a clot in a vein near the brain, and weakness of the face (facial nerve paralysis). They need hospital care.
When to see a doctor
- Swelling, redness or pain behind the ear: get urgent medical help, as this can mean the infection has spread to the bone (mastoiditis)
- Weakness or drooping of one side of the face
- A very high fever or shivering, or a child who seems very unwell, very drowsy or shows signs of serious illness: this is an emergency
- A baby under 12 months with an ear infection, or a child under 5 with fever: see a doctor
- Earache that is not better after three days, or that gets worse quickly at any time
- Fluid coming out of the ear, new hearing loss, vomiting or dizziness
- Ear infection in someone with diabetes, a weak immune system, or long-term heart, lung, kidney or nerve disease
Diagnosis
A doctor diagnoses a middle ear infection by asking about the symptoms and looking into the ear with an otoscope (a small torch with a magnifying lens). The main sign is a red eardrum that bulges outwards because of fluid behind it, or new discharge from the ear that is not caused by an infection of the ear canal. A US guideline advises that an ear infection should not be diagnosed unless there is fluid in the middle ear. Some doctors use an otoscope that puffs a little air at the eardrum to see whether it moves (pneumatic otoscopy), or a test called tympanometry, which checks how the eardrum moves with air pressure.
The doctor also looks for other causes, such as glue ear (fluid without signs of infection), an outer ear infection, or a more serious illness. Young children with fever are checked carefully for other infections. When ear discharge goes on for a long time, a swab of the discharge may be sent to a laboratory to find the germ.
Treatment
- Give regular paracetamol or ibuprofen to ease pain and fever. Your doctor or pharmacist decides the right dose for the child's age or weight. Do not give aspirin to children under 16.
- Wait and watch for most children. Many get better within about three days without antibiotics. Go back to the doctor if there is no improvement after three days, or straight away if the child gets worse or becomes very unwell.
- Your doctor may give a 'back-up' antibiotic prescription to use only if symptoms are not better after three days or get worse quickly.
- An antibiotic may be started straight away for children under 2 with infection in both ears, for anyone with ear discharge, for severe symptoms, or for people who are very unwell or at high risk of complications.
- When an antibiotic is needed, amoxicillin is usually the first choice. People allergic to penicillin are usually given a macrolide such as clarithromycin or erythromycin. If symptoms get worse after 2 to 3 days of the first antibiotic, the doctor may switch to amoxicillin with clavulanic acid. Finish the course as your doctor advises.
- Do not use decongestants or antihistamines for an ear infection; they have not been shown to help and can cause side effects.
- Children who keep getting ear infections, or who have long-lasting discharge or hearing loss, should see a doctor again. For repeated infections, an ear specialist may suggest small tubes in the eardrum (grommets). Long-term preventive antibiotics are not advised.
Medicines in Pakistan
Medicines a doctor may use, by group. Each link opens our page for that medicine, with every brand and its official DRAP price. Your doctor decides which medicine and dose are right for you.
| Group | Role | Medicines |
|---|---|---|
| Pain relievers and fever reducers | main treatment for ear pain and fever, with or without an antibiotic; doctor or pharmacist decides the dose by age or weight | Paracetamol (350 brands), Ibuprofen (378 brands) |
| Penicillin antibiotics | amoxicillin is the usual first choice when an antibiotic is needed; amoxicillin with clavulanic acid is the second choice if symptoms get worse on amoxicillin, or if amoxicillin was used in the past month | Amoxicillin (248 brands), Amoxicillin + clavulanic acid (176 brands) |
| Macrolide antibiotics | alternative for people allergic to penicillin; erythromycin is preferred in pregnancy; a doctor checks for heart rhythm problems before use | Clarithromycin (489 brands), Erythromycin (11 brands) |
Also used (not yet in our price list): Ear drops that combine a local anaesthetic (numbing medicine) with a painkiller, used for ear pain only on a doctor's advice
Self-care and prevention
Self-care
- Give regular pain relief (paracetamol or ibuprofen) as advised by your doctor or pharmacist
- Gently wipe away any discharge from the outside of the ear with clean cotton wool
- Do not push anything into the ear, such as cotton buds, fingers, oil or home remedies
- Keep water and shampoo out of the ear and avoid swimming until the infection has cleared
- Keep a child with a high temperature at home and away from other children until they feel better
- Watch for warning signs and go back to the doctor if the child is not better after three days
Prevention
- Keep your child's vaccines up to date, including the pneumococcal vaccine, and consider the yearly flu vaccine
- Breastfeed only (no other milk or food) for at least the first 6 months if you can
- Keep children away from tobacco smoke
- Avoid giving a dummy (pacifier) after 6 months of age
- Do not push cotton buds or fingers into the ears
Common questions
Does every ear infection need antibiotics?
No. Most middle ear infections get better within about three days without antibiotics, and antibiotics only help a little with pain. Doctors usually give them to children under 2 with infection in both ears, to anyone with ear discharge, or to people who are very unwell or at high risk. Pain relief is the most important treatment.
How long does a middle ear infection last?
Symptoms usually last about three days but can last up to a week. See a doctor if there is no improvement after three days, or sooner if the child gets worse.
Should I put oil or drops in my child's ear?
Do not put oil, cotton buds or home remedies in the ear. They do not treat a middle ear infection and can cause harm, especially if the eardrum has burst. Use only ear drops a doctor has prescribed.
My child's ear is leaking pus. Is that serious?
Discharge from the ear can mean the eardrum has torn because of the infection. The child should see a doctor, as guidelines say an antibiotic is more likely to help when there is discharge. Discharge that goes on for a long time needs a check by an ear specialist.
Can adults get middle ear infections?
Yes, but they are much more common in children. Adults have the same symptoms, such as ear pain, dulled hearing and sometimes fever, and are treated in a similar way. Adults with repeated infections should be checked by a doctor.
Sources
- NICE. Otitis media (acute): antimicrobial prescribing (NG91) (2022).
- NICE. Otitis media (acute): antimicrobial prescribing (NG91) - guideline PDF (NICE document hosted by the Institute of Public Health, Albania) (2018).
- NICE. Otitis media (acute): antimicrobial prescribing guideline. Evidence review (2022).
- American Academy of Pediatrics. The Diagnosis and Management of Acute Otitis Media (clinical practice guideline, Pediatrics 2013;131:e964-e999) (2013).
- NHS. Ear infections (2025).
- NHS Grampian, Orkney and Shetland antimicrobial prescribing guidance. Acute Otitis Media (AOM) | Right Decisions (2026).
- Cureus. Bacterial and Fungal Pathogens in Chronic Suppurative Otitis Media and Otitis Externa With Persistent Otorrhea: A Cross-Sectional Study in a Low- to Middle-Income Country (Pakistan) (2025).
- Journal of Ayub Medical College Abbottabad. Pseudomonas aeruginosa in Chronic Suppurative Otitis Media: Sensitivity Spectrum Against Various Antibiotics in Karachi (2009).
Prepared from the sources listed below by the MedInfoBase team. Last reviewed 16 October 2026. This page is general health information, not medical advice. It gives no doses and does not replace a doctor: talk to your doctor or pharmacist before starting, stopping or changing any medicine. How we write and check our pages.