Middle Ear Infection: Symptoms in Adults and Children

What Is a Middle Ear Infection?

A middle ear infection is fluid or inflammation behind the eardrum, and its symptoms are the same in women and men. What changes is age, not sex: the picture in an adult is not the picture in a small child. The middle ear is a small air-filled space, and in most cases the trouble starts in the nose rather than in the ear. A cold or nasal congestion closes the narrow tube that connects the middle ear to the back of the nose, air is trapped, fluid collects behind the eardrum, and the result is pain or pressure, a blocked ear and muffled sound. Many episodes settle within a few days. Some do not, and those need the ear examined.

This article starts with the basics: what the middle ear is and why it becomes inflamed, then the three types of infection and how to tell them apart, because the urgency and the handling differ from one type to the next. One principle holds throughout: an ear cannot be judged from a description. The eardrum has to be seen directly through an otoscope before anyone can say which type of infection it is and how severe it is. That is why an ear cannot be assessed at a distance, and why Town Hospital does not offer remote assessment of the ear.

To understand what is happening, picture the ear as three regions, one behind the other. The outer ear is the part you can see from outside: the visible flap and the canal that ends at the eardrum. Behind the eardrum sits the middle ear, a small sealed chamber. Beyond it lies the inner ear, which turns sound into nerve signals and shares in the sense of balance. A middle ear infection sits in that middle chamber alone, which is why it cannot be seen from the outside, however long you look at your ear in the mirror.

The middle ear: a small air-filled chamber behind the eardrum

The middle ear is smaller than a broad bean, and it holds the three smallest bones in the body, which carry the vibration of the eardrum through to the inner ear. For them to work, the chamber has to be full of air, and the pressure of that air has to match the pressure outside. Only then does the eardrum vibrate freely and sound arrive clearly.

If the chamber fills with fluid instead of air, or if the pressure inside it falls out of balance, the eardrum is pulled tight and becomes slow to move. The ear feels blocked, sound reaches you muffled as though it were coming through a wall, and your own voice may sound loud or hollow inside your head. That is the heart of the condition: it is a problem of ventilation and drainage before it is a problem of germs.

The eustachian tube: the key to understanding the whole condition

The eustachian tube is a narrow passage connecting the middle ear to the back of the nose and the throat. It normally stays closed and opens for a moment when you swallow or yawn, and in that moment it does three things at once: it lets fresh air into the middle ear, it equalises the pressure on the two sides of the eardrum, and it drains any secretions from the ear into the nose.

When that tube becomes congested or blocked, all three functions stop together. The lining absorbs the trapped air, so a negative pressure builds up that pulls the eardrum inwards and causes pain and clicking. Fluid then seeps from the wall of the chamber to fill the space, and that standing fluid is an ideal place for germs travelling up from the nose and throat to multiply. At that point the problem turns from a blockage into an infection.

This tube is what ties the ear to everything happening in the nose, whether that is a cold, sinusitis or persistent congestion. It is also why treating the ear alone may not be enough while the source of the congestion in the nose is still there.

Children are affected more often, and the reason is anatomical

The reason is anatomical first and foremost. In a young child the eustachian tube is shorter, closer to horizontal and softer-walled than in an adult, so it drains less well and germs travel from the nose to the ear more easily and more quickly. Added to that are the adenoids, which sit at the back of the nose close to the openings of the two tubes and swell with repeated colds until they block the exit.

Other factors that have nothing to do with anatomy raise the odds at this age too: an immune system still learning to recognise germs, frequent colds, and mixing with other children at nursery and school. As a child grows, the tube lengthens, becomes more angled and drains better, so attacks gradually become less frequent with age. None of this means adults are safe, because the same tube can block at any age, but the illness looks different in an adult.

A middle ear infection is not an outer ear infection

The two are often confused, and telling them apart matters, because the site of the problem and the way it is handled are completely different:

Outer ear infection: affects the ear canal you can see from the outside, and is often linked to water getting in or to cleaning the ear with cotton buds. Its telltale sign is that the pain clearly worsens when the outer ear is touched or pulled, or when the small flap of cartilage just in front of the ear opening is pressed, and it may come with itching.
Middle ear infection: sits behind the eardrum, so the pain is deep inside the ear and does not change when the ear is touched from the outside. It usually follows a cold or nasal congestion, and comes with a feeling of fullness and pressure and with reduced hearing.
Inner ear problems: usually show up as dizziness, unsteadiness or ringing, and are a different subject altogether. One important distinction belongs here: a sudden, clear drop in the hearing of one ear, with no pain and no cold before it, is not a middle ear infection. It needs examination the same day rather than waiting to see whether it improves.

These are pointers that help you understand what is going on, not a diagnosis. The only thing that settles it is seeing the eardrum itself through an otoscope.

Types of Middle Ear Infection

Middle ear infection falls into three main types, and what separates them is not how badly it hurts, but two other things: whether there is an active infection right now or only standing fluid, and how long the situation has lasted. Those two things decide how urgent the case is and what needs to be done about it.

Acute infection: a sudden, short-lived attack

This appears suddenly, over hours or a day or two, and usually a few days after a cold. The fluid behind the eardrum is infected and the eardrum itself is congested and bulging, so the pain is obvious and the temperature may rise. The pain typically gets worse on lying down, because congestion increases in that position, which is why the complaint peaks at night and eases somewhat during the day.

Sometimes it ends with a small tear in the eardrum through which discharge escapes, and the pain stops suddenly. That sudden relief is not recovery. It is a sign that the eardrum took more pressure than it could hold until it gave way. Discharge coming out of the ear is one of the signs listed below that call for examination the same day, and the eardrum then has to be followed up until it has healed.

From the moment any discharge appears from the ear, stop putting anything into it: no warm oil, no garlic or herbs, no cotton buds, and no ear drops that were not prescribed by a doctor who has seen the eardrum. The eardrum may be open, and whatever goes into the canal then reaches the middle ear directly. The same ban applies to any painful ear that has not been examined, because no one can tell on their own, or from how much it hurts, whether the eardrum is intact or perforated.

How urgent it is: most attacks settle gradually over a few days, but the ear needs to be examined the same day if the pain is severe and will not settle, if the temperature rises sharply, if discharge comes out of the ear, if there is swelling, redness or tenderness over the bone behind the ear, if there is severe dizziness with vomiting, if one side of the face becomes weak, or if the patient is an infant.

Otitis media with effusion: fluid behind an eardrum that is not inflamed

This is the silent type, and the one that most often passes unnoticed. The fluid is sitting behind the eardrum, but there is no active infection, so usually there is no pain and no fever. It arises in one of two ways: as fluid left behind by an acute attack that settled without that fluid ever draining away, or from the start, when the eustachian tube stays closed for a long stretch with no infection at all.

What you feel here is not pain but heaviness: a blocked ear, as if there were cotton wool in it, muffled sound, clicking when you swallow, and sometimes a slight feeling of being off balance. In children the only sign may be turning the television up, not answering when called, or drifting and losing attention in class.

How urgent it is: this is not an emergency, but it is not something to leave without follow-up either, because hearing stays reduced for as long as the fluid is there. If a blocked ear or reduced hearing carries on for weeks after the cold has gone, what is needed is an examination and a hearing test, not more remedies at home.

A point that concerns adults in particular: if fluid collects behind one eardrum only in an adult, or keeps coming back in the same ear, the examination must not stop at the ear. The nose and the back of the nose, the nasopharynx, have to be examined with an endoscope, because the cause may be a blockage at the nasal end of the eustachian tube. Ear drops do not reach that blockage and do not reveal it, however many times they are repeated.

Chronic and recurrent infection

This heading covers two different patterns. The first is recurrent infection: acute attacks that come back several times over a few months, with the ear normal in between. The second is chronic infection: a lasting hole in the eardrum with discharge that either keeps returning or never stops, and hearing that slowly gets worse.

The distinguishing feature of the second pattern is that the discharge is usually painless. That is why many people live with it for years and treat it as normal, when it is in fact a situation that needs specialist assessment: letting it run on affects hearing and can open the door to complications. Persistent, foul-smelling discharge in particular should not be left to repeated home remedies, and needs a specialist examination to establish what is causing it.

How urgent it is: specialist assessment, not repeated home treatment. When there is a hole in the eardrum, water has to be kept out of the ear while showering or swimming, and nothing should be put into the ear canal to clean it. The same warning signs listed under the acute type apply here, and any of them appearing alongside discharge from the ear calls for examination the same day.

Quick pointers to the likely type

Sudden pain within a day or two of a cold, with a raised temperature: most likely acute infection.
No pain and no fever, but a blocked ear and muffled hearing that have lasted for weeks: most likely fluid behind the eardrum.
Discharge that keeps coming from the ear without pain, or attacks that repeat several times a year: most likely the chronic or recurrent pattern.

These are pointers for orientation only. They are no substitute for an examination, and on their own they are not enough to decide whether a case needs prescribed medicine, because that is the decision of the doctor who can see the eardrum. The two types that affect hearing most in the long run are the least painful of the three, and that is exactly why pain is not a measure of how serious the situation is.

Causes of Middle Ear Infection

In most cases a middle ear infection starts in the nose, not in the ear itself. The middle ear is a small sealed pocket of air behind the eardrum, ventilated and drained through a narrow tube that runs from it to the back of the nose — the eustachian tube. When that tube becomes congested or blocked, ventilation and drainage stop together: fluid is trapped behind the eardrum and becomes an ideal medium for viruses or bacteria from the upper airway to multiply in. That is why anything that keeps the nose repeatedly or continuously congested is a possible cause of middle ear infection, and it is the point that explains why the infection keeps coming back in some people and not in others.

Upper respiratory infection: the most common cause by far

The great majority of cases appear within a few days of a cold, flu or sore throat. The lining of the nose and throat swells, the swelling reaches the opening of the eustachian tube and closes it, and negative pressure then builds inside the sealed space behind the eardrum and draws fluid out of the surrounding tissue. The cold may settle and the nasal symptoms disappear completely while that fluid stays behind the eardrum for weeks afterwards. This is exactly why so many people describe the same thing: the cold has gone, but the ear is still blocked and hearing has not come back.

Why children are affected more than anyone else

In a young child the eustachian tube is shorter, softer and closer to horizontal than it is in an adult, so it blocks more easily and drains collected fluid less effectively. Add to that enlarged adenoids sitting at the back of the nose and obstructing the opening of the tube, the constant round of respiratory infections at nursery and school, and exposure to cigarette smoke at home, which slows the movement of the tiny hairs that clean the nose. These are anatomical and environmental factors, not evidence of a generally weak immune system, and they ease off on their own as the face and skull grow and the angle of the tube changes.

What lies behind the cases seen in adults

Middle ear infection is less common in adults, and when it does occur — particularly if it keeps returning or drags on — there is usually a chronic problem in the nose behind it that is worth looking for, rather than a passing infection of the ear. The most common things sitting behind an adult case are:

Nasal allergy: chronic congestion and a swollen nasal lining close the opening of the eustachian tube time after time, and unless the allergy itself is controlled the problem returns however often the ear alone is treated.
Chronic sinus disease: post-nasal drip — secretions running down the back of the nose — passes directly over the opening of the tube and keeps it permanently swollen. It is one of the most commonly missed causes in an adult who complains of a repeatedly blocked ear.
A deviated nasal septum or enlarged turbinates: these change the path of air through the nose and the way pressure is distributed inside it, so one side becomes more prone to congestion and to blockage of the tube — which is often why the complaint stays in one particular ear.
Acid reflux: this may contribute, because acid reaching the back of the nose during sleep irritates the area around the opening of the tube. It can explain a blocked ear that is most noticeable first thing in the morning.
Smoking and second-hand smoke: smoke impairs the nose's own cleaning mechanism and thickens secretions, so fluid lingers behind the eardrum for longer and the infection is more likely to recur.
A weakened immune system or an uncontrolled chronic illness: respiratory infections last longer and are more severe, which gives them more opportunity to spread to the ear.

Flying, diving and changes in pressure

The eustachian tube is the valve that equalises pressure between the middle ear and the outside world. During a plane's descent, or on the way down underwater, the outside pressure rises quickly; if the tube is congested from a cold or from allergy it will not open, so the eardrum is pulled inwards and fluid collects behind it. The result is sharp pain during the descent, followed by a blocked feeling and muffled hearing that can last for days after the trip. Swallowing, yawning and chewing gum during the descent all help the tube to open. Travelling or diving at the peak of a cold, or with a badly congested nose, is the situation most likely of all to end in ear pain and a blockage that outlasts the journey.

Symptoms of Middle Ear Infection

Symptoms usually begin with the signs of a cold or a sore throat, such as a blocked or runny nose, and the ear complaint then appears within a day or two as fluid gathers behind the eardrum. The symptoms are the same in men and in women; there is no separate form of middle ear infection that marks one sex out from the other. The real difference is between an adult and a child, because a small child cannot describe what they are feeling, so the illness shows itself as crying, fever and broken sleep, while an adult describes blockage, pressure and muffled hearing.

The main symptoms, and what they actually feel like

Ear pain: throbbing or pressing from inside, worse when you lie down and worse with coughing or bending forward. It is usually at its worst at night, because lying flat increases congestion in the nose.
A feeling of fullness or blockage: as though the ear is plugged with cotton wool, or as though you are inside a tunnel, and it does not clear on swallowing the way the brief blockage on a flight does.
Muffled or distorted hearing: sounds seem distant and unclear, and it becomes much harder to follow a conversation in a noisy place or when more than one person is speaking.
Hearing your own voice loudly inside your head: a common complaint when there is fluid in the middle ear or a problem with its ventilation, and some people describe their voice echoing in the ear as they speak. On its own it is not conclusive, because it also occurs with other disorders of eustachian tube function, so it is read alongside the rest of the symptoms and the examination.
Clicking or popping on swallowing: the sound of the tube trying to open and equalise the pressure. It may bring a moment's relief before the blockage returns.
Tinnitus: a continuous ringing or hissing, clearest in a quiet room and at bedtime.
A raised temperature: far more obvious in children; in an adult it may be slight or absent altogether.
A mild sense of being off balance: slight unsteadiness or heaviness in the head alongside the blockage. Severe dizziness with vomiting, or being unable to stand, is something entirely different and appears among the red flags at the end of this section.
Discharge from the ear: fluid or pus coming out of the ear canal. It usually means that the pressure that had built up has made a small hole in the eardrum, which is why the pain stops suddenly at that same moment.

An important warning when there is discharge: fluid or pus coming from the ear means the eardrum may be perforated, and in that situation nothing at all should go into the ear — no olive oil, no garlic, no warm water, no herbal remedies, and no drops left over from an old prescription or prescribed for somebody else. Whatever passes through the hole reaches the middle ear directly, and it can worsen the infection or harm hearing. The right thing to do is to dry the ear from the outside only, keep water out of it while showering or swimming, and have it examined so the doctor can decide what the case needs after seeing the eardrum.

Not every earache comes from the middle ear. In adults especially, pain can arise in the jaw joint, the teeth or the throat and be felt inside the ear while the eardrum is completely normal on examination. Earache with no blockage, no hearing loss and no preceding cold therefore deserves an examination to find where it is really coming from, rather than being assumed to be an infection and treated as one.

Do the symptoms of middle ear infection in women differ from those in men?

No. There is no meaningful difference between the symptoms of middle ear infection in women and in men: the anatomy is the same, the mechanism is the same and the complaint is the same — pain, blockage, pressure and muffled hearing, with or without a raised temperature. There is no separate list of symptoms for women.

The question is asked for a good reason, though. Almost everything written about middle ear infection is written about children: crying, pulling at the ear, fever, refusing feeds. When an adult woman reads that description she finds nothing in it that resembles what she is experiencing, because what she is experiencing is the adult picture and not the child's. So the difference she has noticed is real, but it is a difference between an adult and a child, not between a woman and a man. Any list presented as symptoms specific to one sex is really the same list of symptoms under a different heading.

The one genuine exception is not in the symptoms at all. It is pregnancy and breastfeeding, which change what medicine can be prescribed, and which also change how likely it is that persistent nasal congestion is sitting behind the ear complaint in the first place. Both are set out below.

Symptoms of middle ear infection in adults

The infection is less common in adults than in children, and it looks different. The dominant complaint in an adult is a blocked ear, pressure inside it and muffled hearing, rather than the high fever and sharp pain that wake a small child from sleep. It very often affects one ear only, and the pain may be moderate or even absent while the hearing loss is the symptom that finally sends the person looking for an explanation.

What the adult picture tends to look like:

It usually begins after a cold, a bout of allergy or a flight, and sometimes with no obvious infection at all.
The complaint is on one side in most cases, unlike a child, in whom both ears are frequently affected together.
Pressure, fullness and muffled hearing that carry on for weeks after the cold symptoms have gone.
A slight temperature or none at all; the absence of fever does not rule out fluid behind the eardrum.
Tiredness and difficulty concentrating in noise, because the brain is working harder to pick up speech with one good ear.
A mild feeling of unsteadiness or heaviness in the head that comes with the blockage and clears when it clears.

The practical conclusion for an adult: do not wait for a fever or for severe pain before taking this seriously. Muffled hearing in one ear that does not improve is reason enough to have the ear examined.

Fluid that persists or keeps returning in one ear in an adult: examine the nose, not the ear alone

This is the most important thing an adult reader can take away from this page. The rule in adults is not the rule in children. In many children it is acceptable to wait and watch until the fluid drains and clears by itself. In an adult, fluid that settles behind one eardrum and does not clear within a few weeks, or that clears and then returns to the same ear time after time, calls for examination of the nose and the nasopharynx without delay. Do not wait months, and do not settle for repeating treatment applied to the ear.

The reason is that the source of the problem may sit at the opening of the eustachian tube at the back of the nose rather than inside the ear: chronic congestion, uncontrolled allergy, sinus disease, enlarged tissue, or a mass that needs to be diagnosed. None of this can be seen through an ear scope or by looking into the throat; it is seen with a nasal endoscope in an ENT clinic. In most cases the cause turns out to be simple and treatable, but confirming that takes one look, and no amount of repeated ear drops is a substitute for it.

Repeating treatment aimed at the ear alone in this situation does not treat the cause. It delays the diagnosis and prolongs the period of reduced hearing. This examination is carried out at the ENT clinic at Town Hospital in New Cairo (Fifth Settlement). An ear cannot be assessed remotely: examining the ear and the nose requires looking at them directly, and the hospital does not provide remote consultations.

Middle ear infection during pregnancy and breastfeeding

The symptoms in pregnancy are the same: pain, blockage, pressure and muffled hearing. Two things, however, genuinely do differ.

The first is that nasal congestion is extremely common in pregnancy in its own right. Hormonal changes and the increase in blood volume leave the lining of the nose swollen and congested for weeks or months without any cold and without any allergy, and that congestion reaches the opening of the eustachian tube, producing a blocked ear, popping and muffled hearing, and sometimes paving the way for fluid to collect behind the eardrum. It usually improves after delivery, but during pregnancy it makes ear complaints more frequent and longer-lasting.

The second is that what can be prescribed is different. Some decongestants, and some of the pain and fever medicines sold at the pharmacy without a prescription, are not suitable in pregnancy or while breastfeeding. That decision belongs neither to the patient nor to the pharmacist, but to the doctor who examines the ear and knows how many weeks pregnant you are or how old your baby is. So:

Tell the doctor that you are pregnant or breastfeeding at the start of the visit, and say how many weeks pregnant you are or how old your baby is, before you describe the symptoms.
Do not use medicine left over from an earlier prescription, medicine prescribed for somebody else, or whatever is suggested to you at the pharmacy without an examination.
An untreated infection is not the safe option either. The aim is proper treatment prescribed for your situation, not avoiding treatment out of fear.
Pregnancy is not a barrier to having the ear examined or to nasal endoscopy. Both are simple examinations and neither involves any radiation.
Do not put the examination off until after delivery on the assumption that nothing can be done now. The assessment itself does no harm; the delay is what may do harm.

The same principle applies while breastfeeding. Most cases can be handled safely, but it is the doctor who decides that, and the doctor has to know that you are breastfeeding before prescribing anything.

Symptoms of middle ear infection in children

A small child does not complain of a blocked ear or of muffled hearing; the illness shows itself in behaviour. Watch for:

Constant crying that worsens at night and on lying down, with obvious difficulty sleeping.
Pulling at the ear, rubbing it, or repeatedly hitting it with the hand.
A raised temperature after a cold.
Refusing feeds or food, because swallowing and sucking make the pain worse.
Irritability and no response when called from a distance, or turning the television up.
Loss of balance or frequent stumbling in a child who has started walking.
Discharge from the ear, after which the child often settles suddenly.

It is worth remembering that fluid can sit behind the eardrum with no pain and no fever while hearing quietly weakens. A child who gets repeated infections, whose speech is late, or who constantly turns devices up, needs to be seen by a doctor even if they seem perfectly well.

When the visit must be immediate, and when watching at home is enough

The following signs mean an examination now or the same day, not waiting until tomorrow and not trying a remedy at home:

Severe pain that stops suddenly and is followed by fluid or pus coming from the ear: the sudden end of the pain is not recovery here; it usually points to a hole in the eardrum. Have the ear examined the same day, and put nothing into it beforehand.
Swelling, redness or pain in the bone behind the ear, or the outer ear pushed forward and away from the head: immediate examination, within the hour; at night or on a holiday, go to the emergency department.
Weakness or numbness of the facial muscles on the same side, such as the mouth pulling to one side or difficulty closing the eye: immediately, within the hour.
Severe dizziness with vomiting, or being unable to stand and walk: immediately, within the hour.
Severe headache with a stiff neck, marked drowsiness, a change in the level of consciousness, or a seizure: emergency department, immediately.
Fever in a baby under three months, or a listless child who refuses feeds and is not responding as usual: immediate examination within the hour, however settled the child appears between episodes.
Sudden hearing loss in one ear over hours or within a day, especially with no pain and no preceding cold: examination the same day. Do not assume it is wax or simply fluid behind the eardrum, because some cases of sudden hearing loss need rapid assessment that cannot be put off for days.
Hearing that does not return to normal after the pain and the fever have gone: if it lasts more than two weeks, ask for an examination within days rather than waiting for it to sort itself out.
An ear infection in someone with an uncontrolled chronic illness or a weakened immune system: early examination the same day, because the infection may take a different course in them.

What can reasonably be watched at home for a day or two is the mild case in an adult, or in a child over two: bearable pain, no high fever, no discharge, no dizziness and none of the signs listed above, with gradual day-by-day improvement, especially when it has come directly after a cold. A child under two, and a baby in particular, should not be watched at home; they need a doctor to examine the ear.

The measure is simple: which way things are moving overall. If the pain is easing and the blockage is lessening, watching is reasonable. If the symptoms stay exactly where they are or get worse, or any of the signs above appears, the time for watching is over.

One final point. Watching at home means monitoring the symptoms, not buying medicine at the pharmacy without an examination. Some cases genuinely do need treatment prescribed by a doctor, but deciding whether it is needed and choosing it belong to the doctor who looks inside the ear and sees the eardrum. Medicine left over from a previous illness is no substitute for that examination, nor is medicine prescribed for a relative or a neighbour, nor is whatever is suggested from the shelf at the pharmacy.

How is middle ear infection diagnosed?

Middle ear infection is not diagnosed from a description of symptoms. It is diagnosed by looking directly at the eardrum. Pain, blockage and reduced hearing can all come from an infection in the outer ear canal, from a build-up of wax, or from fluid sitting behind the eardrum with no active infection at all — and each of those needs completely different handling. So the first step is a direct examination of the ear by an ENT doctor. It is also why Town Hospital does not assess ear problems remotely: an ear cannot be judged without being looked at.

Looking at the eardrum with an otoscope

An otoscope is a small instrument that combines a light and a magnifying lens. Its tip is placed at the entrance of the ear canal so the doctor can see the surface of the eardrum. The examination takes seconds and is not painful in normal circumstances, although it can be briefly uncomfortable when the ear is inflamed. The doctor may use an otoscope fitted with a small bulb that pushes a gentle puff of air against the eardrum to test how well it moves, because an eardrum that moves poorly usually means there is fluid behind it.

What the eardrum looks like is the decisive piece of information in the diagnosis. The doctor looks for:

The colour of the eardrum — translucent and its normal colour, red and congested, or yellowish because of fluid behind it.
Bulging of the eardrum outwards, a sign of fluid or pus trapped under pressure in the middle ear.
The eardrum pulled inwards, which points to long-standing poor ventilation of the ear rather than to an acute infection.
Loss of the eardrum’s normal landmarks, and of the light reflex from its surface.
A visible fluid level or air bubbles behind the eardrum.
A hole in the eardrum, or discharge coming through it.
The state of the ear canal itself — swelling or redness there points to a completely different diagnosis.

This difference in appearance is what decides the treatment plan. A bulging, congested eardrum with cloudy fluid behind it points to an active acute infection, while a quiet eardrum with clear fluid still sitting behind it after the infection has cleared is a different situation that is not treated the same way. The two cannot be told apart without looking at the eardrum.

Measuring ear pressure and eardrum movement

This test is known as tympanometry. A small probe is placed at the entrance of the ear; it changes the pressure slightly and records the eardrum’s response as a graph. It is painless, takes no more than a minute, and asks nothing of the patient except to sit still without talking or swallowing.

Its value is that it turns a visual impression into a documented measurement. It picks up fluid behind the eardrum even when that fluid is hard to see, it shows whether the ear is ventilating poorly, and it can be repeated at later visits to tell whether the fluid is genuinely clearing or staying exactly where it was. That is why it is usually requested when the main complaint is blockage or muffled hearing without obvious pain, or when infections keep coming back. It is always done on both ears, because comparing the two sides is the only thing that reveals a problem confined to one ear — and that single fact changes the whole direction of the assessment.

Hearing tests

A hearing test is requested when fluid remains behind the eardrum after the infection has settled, when a patient complains of persistent hearing loss, or when infections keep recurring. It measures how much hearing has been lost and what kind of loss it is. It separates loss caused by a mechanical obstacle in the middle ear — the expected kind when fluid is present, which usually improves once the fluid clears — from loss arising in the inner ear or the hearing nerve, which is a different matter and calls for a different line of assessment.

The test matters even more in children, because hearing loss during the years when speech is being learned can pass unnoticed by everyone around the child. It shows up as delayed speech, poor attention, or turning the television up — not as a complaint about the ear.

Examining the nose and the nasopharynx

The examination does not stop at the ear. The eustachian tube ends in the nasopharynx, behind the nose, and whatever is happening there — congestion, allergy, inflammation or obstruction — has a direct effect on how well the middle ear is ventilated. So the doctor examines the nose and throat at the same visit, and may use a thin flexible endoscope to see the opening of the eustachian tube from the inside, particularly when infections keep recurring or fluid persists after the symptoms have gone.

In one situation in particular, this examination is not optional but essential: an adult with fluid behind the eardrum on one side only, which persists or keeps returning after the cold has passed. Middle ear infection is not as common in adults as it is in children, and when it appears on one side and refuses to settle, the cause usually lies outside the ear itself — something blocking the opening of the eustachian tube in the nasopharynx, whether congestion, long-standing allergy, enlarged tissue, or an abnormal growth in that area. None of it can be seen without examining the nose and nasopharynx directly.

This is why repeating ear drops, or running the same treatment again and again without examining the nose and nasopharynx, is the most costly mistake in this specific situation. It eases the symptom while postponing a diagnosis that should have been ruled out early. In children, by contrast, fluid in both ears after repeated colds is expected, and is followed up in a different way.

When imaging is considered

Imaging is not part of the usual diagnosis, and the great majority of cases are diagnosed on clinical examination alone. A doctor may turn to a CT or MRI scan in specific situations, chiefly a suspicion that the infection has spread beyond the middle ear, chronic infection with continuing discharge, or planning for a surgical procedure.

How middle ear infection is treated

The treatment plan differs with the patient’s age, how severe the symptoms are, what the eardrum looks like on examination, and whether other conditions are present alongside it. As a general rule, a large proportion of acute middle ear infections improve with pain and fever control plus follow-up, because many of them are viral to begin with. The rest need a prescribed medicine — and the only way to tell the two groups apart is to examine the ear.

Controlling pain and fever comes first

Relieving pain is not a secondary measure while waiting for the “real treatment”. It is the first step in treatment, and the one that makes the most difference to how the patient feels through the first two days, which are usually the hardest. Pain and fever relief is what is used for this, and the doctor decides which type and what dose according to age and weight.

This matters more in some situations than in others. Anyone taking other medicines regularly, or living with a long-standing stomach, kidney or blood-clotting problem, should ask the doctor before taking any painkiller. The same applies during pregnancy and breastfeeding, when what is safe to take is not the same as at other times: the decision belongs to the doctor, not to whatever is already in the house, or whatever can be bought without a prescription.

Follow-up and observation instead of rushing

After examining the ear, the doctor may decide to keep the case under observation with pain relief and no additional medicine. That is a recognised treatment decision, not neglect. It rests on what the doctor saw at the eardrum, on the patient’s age, and on how severe the symptoms are, and it always comes with a review appointment and clear signs that mean coming back sooner. What matters is that the decision is made by the person who examined the ear, not taken at home as a decision to wait and see.

Antibiotics: the decision of the doctor who examined the ear

Some cases genuinely do need a prescribed antibiotic. Whether to prescribe one at all, which one to choose, and how long it should be taken for are all decisions that belong to the doctor who has looked at the eardrum. That doctor builds the decision on what was seen inside the ear, together with the patient’s age, general health, and the way the symptoms have behaved. None of that information is complete without the examination, and none of it is something a patient can weigh up alone, whether for their own need for medicine or their child’s.

What is left over in an old box, what was prescribed for another child in the family, or what someone suggests from a description of the symptoms without seeing the ear, is no substitute for that examination. The wrong medicine does not treat the condition. It may relieve the symptoms just enough to delay the correct diagnosis, it exposes the patient to side effects for no benefit, and it contributes to bacteria becoming resistant to antibiotics — a real problem that makes the next infection harder to treat.

If the doctor does prescribe an antibiotic, it must be taken exactly as prescribed and not stopped the moment the pain goes, because pain usually settles before the infection has finished. In certain cases the doctor may also prescribe ear drops, after checking the state of the eardrum — which is an entirely different thing from deciding to put drops in without an examination.

What genuinely helps at home

Pain and fever relief in the form the doctor specified, at regular times through the worst days, rather than waiting for the pain to build up.
A warm — not hot — compress held against the outside of the ear for a few minutes; it eases the feeling of pressure.
Raising the head on an extra pillow at night, since the pain usually gets worse lying flat.
Plenty of fluids and rest, especially when there is a fever.
A sterile saline nasal rinse to ease congestion, clearing the nose gently rather than blowing hard.
Keeping the patient away from cigarette smoke indoors for the whole of the illness; smoke adds irritation and slows recovery.

What should be avoided

Pouring oils — olive oil, castor oil or any other — or garlic or onion juice, or any home remedy, into the ear. These are common practices that do not treat a middle ear infection, because anything placed in the outer canal never reaches behind an intact eardrum in the first place.
Putting any drops into the ear without a doctor’s prescription, and above all if there is any discharge coming out of the ear. Discharge means the eardrum may be perforated, in which case whatever is poured in reaches the middle ear directly, and some of these substances damage the middle ear and damage hearing.
Pushing cotton buds or anything else into the ear to clean it or to dry the discharge; wiping away what comes out with a clean cloth is enough.
Letting water into the ear while there is discharge or a perforation, whether swimming or showering, until the doctor says otherwise.
Using leftover medicine, or medicine prescribed for someone else, or repeating an old prescription on a new infection.

When fluid stays behind the eardrum

It is common for the infection to clear and the pain and fever to go, and then for a sense of blockage and muffled hearing to stay for weeks. This is usually residual fluid behind a quiet eardrum rather than an active infection. It does not call for medicine to kill germs, but for follow-up until the ear’s ventilation returns to normal — and a great many of these cases settle gradually on their own.

If the fluid lasts more than three months, clearly affects hearing, or stays in one ear in an adult, a full reassessment is needed: tympanometry, a hearing test, and an examination of the nose and nasopharynx to find what is stopping the eustachian tube from ventilating the ear — the examination that cannot be skipped in an adult complaining about one ear, as set out above. Once the assessment is complete, the doctor may discuss a further step, such as draining the fluid and ventilating the ear through a small tube placed in the eardrum. That decision is made case by case, according to the hearing level, the patient’s age, and how long the fluid has been there.

Complications of middle ear infection

Most middle ear infections heal without leaving a trace. Complications are not common, but they are real, and they become more likely when an infection is left without assessment, keeps recurring without anyone looking for the reason, or is treated with medicines taken at random that hide the symptoms without solving the problem. The point of setting them out here is not to cause alarm. It is to make the sign that calls for action recognisable — and to make clear when that action is today rather than tomorrow.

Hearing loss

The most common of these is temporary hearing loss, which lasts as long as the fluid does and usually goes when it clears. But repeated infections, or fluid that stays for months, can stretch that period out, and this is where the real effect shows: delayed speech and poor attention in children who are still learning to talk, and, in adults, difficulty following meetings and phone calls or coping in noisy places. Less often, repeated damage to the eardrum or to the small hearing bones behind it can make part of the loss permanent. That is why hearing which has not returned to normal after the infection has ended deserves to be measured, not waited out indefinitely.

A perforated eardrum

When pressure from fluid or pus behind the eardrum builds up, a small hole can open in it. The giveaway sign is that severe pain suddenly eases and discharge comes out of the ear. This is not a reason to panic, but it is not a reason to relax and stop following it up either. What is needed is to keep the ear completely dry, put nothing into it at all, and have it seen by a doctor within a day or two to check the size of the hole and follow its healing. Most of these perforations close on their own within weeks, under the doctor’s follow-up. One that does not close can turn into a chronic perforation, with recurring infection and reduced hearing, and needs assessment for repair.

Mastoiditis

The mastoid is the porous, honeycombed bone lying directly behind the ear, and in uncommon cases the infection can spread into it. Its signs are obvious and need no expertise to spot: swelling, redness or pain when the area behind the ear is touched; the outer ear pushed forwards or outwards compared with the other side; a high fever; and pain that is getting worse instead of easing. This means going to hospital the same day, and it is not managed at home with any medicine.

Chronic infection and abnormal tissue inside the ear

Continuous or recurring discharge from the ear, especially when it smells foul and comes with gradually worsening hearing, is not something to live with. It can point to chronic infection, or to a build-up of abnormal skin tissue inside the middle ear known as a cholesteatoma, which over time can erode the bone next to it and spread into the structures around it. Diagnosing these conditions needs specialist examination, and treating them is usually surgical rather than a matter of repeated courses of medicine.

Infection spreading beyond the ear

In rare cases the infection can extend beyond the middle ear: to the facial nerve, which runs close by, causing weakness on one side of the face; or to the inner ear, causing severe vertigo with sudden hearing loss; or to the membranes surrounding the brain (meningitis). These are emergencies, assessed in hospital immediately — and they are precisely the reason that a severe infection, or one that is not improving, should never be left without an examination.

Signs that mean going to hospital the same day

Swelling, redness or pain behind the outer ear, or the ear pushed forwards compared with the other side.
A severe headache with a stiff neck, repeated vomiting, drowsiness or difficulty waking, or confusion.
Weakness on one side of the face, a drooping corner of the mouth, or being unable to close the eye on one side.
Severe dizziness with vomiting, or being unable to stand and walk.
Sudden, clear loss of hearing.
A high fever that does not respond to fever relief, or pain that intensifies instead of easing.
A seizure, or an infant with a fever who cries continuously and refuses to feed.

Signs that mean having the ear examined within a day or two

Severe pain that suddenly eases and is followed by fluid or pus coming out of the ear. This is the sign of a perforated eardrum: keep the ear dry, put nothing into it, and have it seen by a doctor.
Pain that has not begun to improve after two days despite taking pain relief regularly, or pain that settled and then came back. That is a reason to have the ear re-examined, not to try a new medicine at home.
Discharge from the ear that continues for more than a few days, or that starts to smell foul.
Muffled hearing or a sense of blockage that lasts for weeks after a cold has cleared, and above all if it is in one ear in an adult.
Ear infections recurring more than once within a short period, because the recurrence itself is what needs explaining.

The simple rule that ties all of this together is that the ear is an organ examined by looking at it: any pain, discharge or hearing loss that does not end when the cold ends deserves a direct examination, not one medicine after another tried at home.

Preventing Middle Ear Infection

Middle ear infection cannot be prevented entirely, but how often it happens can be reduced considerably. Everything that genuinely helps works on one of two fronts: cutting down the number of colds that reach the child, and keeping the eustachian tube open so that the ear can ventilate itself.

Three things that make most of the difference at home

If a family can change only three things, these are the three to choose — they are the ones the household actually controls:

A completely smoke-free home and car.
Nasal allergy properly controlled with regular treatment, rather than simply lived with.
Feeding the baby propped up at an angle, and never leaving the baby in bed with a bottle.

Smoke inside the home and the car

Second-hand smoke is one of the strongest modifiable risk factors for repeated ear infection in children, and one of the most underestimated in our homes. Cigarette and shisha smoke swells the lining of the nose around the opening of the eustachian tube and paralyses the tiny hairs that move mucus along, so the ear ventilates poorly and fluid stays trapped for weeks after what was only a passing cold.

No smoking inside the home, and none at all in the car, even with a window open — the fine particles stay suspended in the air for a long time.
Stepping onto the balcony to smoke and then coming back in to carry the child does not undo the effect: smoke residue clings to clothes, hair and hands.
Shisha is no gentler than cigarettes, and the effect builds up over time. The difference shows when the whole household is smoke-free, not when one person cuts down.

Treating nasal allergy instead of living with it

A permanently blocked nose and morning sneezing are often treated as just the way someone is, rather than as a condition that needs treating. But ongoing inflammation in the lining of the nose keeps the opening of the eustachian tube swollen for weeks at a time. The ear loses its ventilation, and after that an ordinary virus is enough to tip it into a full infection. Controlling the nose continuously protects the ear in a way that treatment started only once the pain begins never can.

Year-round nasal allergy (allergic rhinitis) — dust mites in mattresses, old pillows and carpets — needs continuous control, not treatment only when it flares.
Dusty, windy seasons such as the Khamaseen, along with traffic fumes, make symptoms worse; at those times, closing the car windows and setting the air to recirculate helps.
Rinsing the nose with saline is simple and safe for adults and children alike, and helps drain mucus and ease congestion without medication.
When medication is needed — classes such as antihistamines, or a prescribed nasal spray — the doctor decides according to age and condition. What matters with these is using them consistently rather than on and off.

Feeding position for babies

A baby's eustachian tube is short and almost horizontal, so feeding while lying flat on the back makes it easy for milk to travel back towards the opening of the tube and irritate it.

Raise the baby's head and chest on your arm at a clear incline — with breast and bottle feeding alike.
Do not prop the bottle on a pillow and leave the baby to feed alone: the flow continues even when the baby stops swallowing, and nobody is beside the baby to notice the milk coming back up.
Do not let the baby fall asleep with the bottle still in the mouth, and hold the baby upright for a few minutes after the feed.
Moving gradually away from the bottle and the pacifier (dummy) after the first year reduces the repeated sucking that affects pressure in the middle ear.

Breastfeeding is associated with fewer ear infections in the first year, thanks both to the antibodies it carries and to a feeding position that involves less reflux. This is offered as guidance, not as a way of placing blame on anyone: a mother who cannot breastfeed for a medical or practical reason can protect her child with everything else described here.

Hand hygiene, crowding and nursery care

Most episodes begin as a viral infection in the nose and throat and then travel up to the ear, so every cold that is avoided is a possible ear infection avoided with it.

Wash hands with soap and water on coming in from outside, before eating, and after wiping a child's nose — and do not let children in the same home share cups or tissues.
Large nurseries clearly raise the rate of respiratory infections, so where it is possible, a smaller group is better for a child who gets these infections repeatedly.
Keeping a child at home while they have a cold breaks the cycle of infection that otherwise comes back round to the same child.

Ear pressure on flights and while diving

When the pressure outside changes, the middle ear has to equalise it through the eustachian tube — and landing is harder than take-off, because the tube opens with more difficulty on the way down.

For adults and older children: swallow repeatedly, yawn or chew gum during both the climb and the descent.
For a baby: breastfeed, or offer the bottle or the pacifier, specifically during the descent — and avoid letting the baby sleep through the whole descent, because we swallow far less often while asleep.
Flying or diving with a badly blocked nose or an active cold makes equalising the pressure much harder, and can injure the ear and tear the eardrum. Ask a doctor before travelling, and postpone the dive altogether. If you are diving, never keep going deeper once you feel pain — the pain is the signal that the pressure has not equalised.

Do not put anything inside the ear canal

Cotton buds, warm oil, herbal drops, hydrogen peroxide — a widespread habit with no preventive value whatsoever. Middle ear infection starts behind the eardrum, and its route in is through the nose, not through the outer canal. So whatever is put into the canal never reaches the place where the problem is — but it does cause harm:

A cotton bud pushes wax further in and forms a plug that blocks the view of the eardrum and delays a correct diagnosis.
Scratching the thin skin of the canal opens the door to infection of the outer ear, which is an entirely different problem.
If the eardrum is perforated — and many families have no idea that it is — oils and liquids go straight into the middle ear and make the infection worse. The ear cleans itself; wiping the outer ear is all that is needed.

When infections keep coming back, start at the nose, not the ear

When episodes repeat several times in a year, or fluid stays behind the eardrum between one episode and the next, the ear is usually the victim rather than the source — in an adult just as much as in a child. The source is higher up: allergy that is not under control, chronic sinus infection, or enlarged adenoids blocking the opening of the eustachian tube. Treating the ear alone with every episode treats the result and leaves the cause in place. Having the nose and the nasopharynx assessed by an ENT doctor is what breaks the cycle.

A few final practical points

Keeping to the routine childhood vaccination schedule reduces a number of the respiratory infections that come before an ear infection. Handling a cold well — rest, fluids and nasal rinsing — shortens the time the eustachian tube stays blocked.
Antibiotics are not a preventive measure. Taking them on your own initiative with every cold does not prevent ear infection, and it makes them less effective on the day they are genuinely needed. That decision belongs to a doctor who has examined the ear.

Prevention does not mean a guarantee against infection; it means fewer episodes and milder ones. Any child who gets these infections repeatedly, or who shows reduced hearing or delayed speech, needs a medical assessment.

Frequently Asked Questions About Middle Ear Infection

Are the symptoms of a middle ear infection different in women?

No, they do not differ: a middle ear infection produces the same symptoms in women as in men, and there is no separate list of symptoms that belongs to women. Pain, a feeling of pressure, muffled hearing, dizziness and fever appear in the same way in both, because the anatomy is the same and the mechanism is the same, and there is no difference of any clinical significance in the way the illness shows itself in one compared with the other. The question comes up so often because almost everything written about middle ear infection is written about children, so an adult reads it, finds nothing that matches what she is feeling, and concludes that her case must be something different. The real difference is not between a woman and a man but between an adult and a child: in adults the complaint is usually a blocked ear and muffled hearing rather than the high fever and constant crying of a small child. The one genuine sex-linked exception is pregnancy and breastfeeding, and it is an exception that affects which medicine can be prescribed, not what the illness looks like.

How does a middle ear infection show in adults, and how is it different in children?

In an adult a middle ear infection is quieter and harder to recognise than it is in a child: pain or heaviness usually in one ear only, a blocked feeling in that ear, muffled hearing, sound coming through with an echo, and sometimes mild dizziness with little or no fever. In a child it is loud and obvious: a sudden high temperature, crying and restlessness through the night, constant pulling or rubbing at the ear, and refusing feeds or food. Middle ear infection is also less common in adults to begin with. That is why fluid that stays behind one eardrum in an adult, or an infection that keeps coming back to the same ear, calls for the nose and the nasopharynx to be examined for something blocking the opening of the eustachian tube. Repeating ear drops and local treatment again and again without that examination is the most costly mistake made with this condition: it eases the symptom while the cause sits higher up, unexamined and untreated.

Is a middle ear infection dangerous, and can it affect hearing permanently?

In most cases a middle ear infection is not dangerous, and it settles without leaving any lasting effect on hearing. The hearing loss that comes with it is usually temporary: fluid behind the eardrum stops it vibrating freely, and hearing returns gradually as that fluid clears. The danger comes from ignoring the infection, or from repeated infections that are never followed up. Fluid that stays for months, or infection that keeps returning to the same ear, can lead to a hole in the eardrum or to hearing loss that lasts, and in rare cases to the infection spreading to the bone behind the ear or beyond it. Some signs need to be assessed the same day rather than waited out: swelling, redness or pain over the bone behind the ear, or the ear being pushed forward so that it sticks out; a severe headache; a high fever that will not come down; a stiff neck; severe dizziness with vomiting, or with being unable to stand; weakness on one side of the face; or unusual drowsiness or confusion, especially in a child.

How long does a middle ear infection take to settle, and when should I go back to the doctor?

Most acute middle ear infections begin to improve within two to three days, and the pain is the first thing to ease. The blocked feeling and the muffled hearing can carry on for weeks after the pain has gone, because the fluid left behind the eardrum needs time to be absorbed; on its own, that is not a sign that treatment has failed. Go back to the doctor if there is no improvement at all in that time, or if things get worse at any point. Go back sooner if the pain increases instead of easing, if fever persists or returns after an improvement, or if discharge comes out of the ear — above all when the pain stopped suddenly at the same moment. The same applies if dizziness or loss of balance appears, particularly with vomiting; if there is pain or swelling over the bone behind the ear; or if the infection returns to the same ear more than once over a few months. And if hearing is still muffled and the ear still feels blocked weeks after everything else has settled, hearing should be measured rather than waited out.

Does every middle ear infection need an antibiotic?

No — not every middle ear infection needs an antibiotic. Many are viral, and many settle on their own with pain and fever relief and careful watching of the symptoms, while other cases genuinely do need a prescribed antibiotic. Telling the two apart is not something a patient can judge from the character of the pain, from how severe it feels, or from a previous episode. The whole decision — whether to prescribe at all, which medicine, how long it is taken, and even the decision to wait and watch instead — rests on seeing the eardrum through an otoscope, on the patient’s age, on how severe the illness is, and on whether one ear or both are involved, not on a description of symptoms. That is why an antibiotic should never be bought at the pharmacy on personal judgement, and why what is left over from an earlier illness, or what was prescribed for somebody else, is no substitute for that examination: it can mask the picture, delay the correct diagnosis and leave the real cause untreated. An ear cannot be assessed without being looked at.

Fluid or pus came out of my ear, what does that mean, and is it an emergency?

Fluid or pus coming out of the ear usually means that pressure behind the eardrum rose until it made a small hole, and what was trapped behind it drained out; that is why many people notice the pain ease suddenly at the very same moment. In most cases it is not an emergency in itself, but it does mean the ear must be examined within a day or two rather than left alone, because the hole needs to be followed up until it heals, and hearing needs to be checked to confirm it has come back to normal. Until then the ear stays completely dry: no swimming, and water kept out of it while showering. Nothing goes into it either — no cotton buds, no oils, and no drops of any kind without an examination and a prescription, because some drops are not safe when the eardrum is perforated. Get the ear assessed the same day if the discharge comes with a high fever, a severe headache, swelling behind the ear, severe dizziness or weakness of the face; if it is real bleeding rather than the light blood-staining that can come with the first discharge; or if it carries on for weeks.

Is a middle ear infection contagious?

The middle ear infection itself does not pass from one person to another, because it is not an infection that travels through the air; it is the result of a blocked eustachian tube and fluid collecting behind the eardrum. What does pass from person to person is the cold or the respiratory infection that comes before it and paves the way for it, and that spreads in the usual way. So nobody needs to be kept away from others because of their ear. What lowers the risk for the rest of the household is hand washing, covering the mouth when coughing, keeping rooms ventilated, and no smoking indoors. If there is discharge from the ear, it is enough not to share towels and pillows.

Can I fly, swim or dive while I have a middle ear infection?

Flying is usually possible but painful, swimming waits until a doctor has checked the ear, and diving is off limits altogether. The reason is the same in all three: a congested ear cannot equalise pressure. Flying is not medically forbidden in most cases, but the pain sharpens during take-off and landing and hearing can be affected temporarily, so non-essential trips are better postponed until the ear settles; if travel is unavoidable, swallowing repeatedly, yawning and chewing something during the descent all help the eustachian tube open, as does feeding a baby or giving a child a drink at that same point, while decongestants should not be used without asking the doctor. Swimming waits until a doctor confirms that the eardrum is intact and that there is no discharge, because water entering an ear with a perforated eardrum opens a direct route for infection. Diving is ruled out completely while there is an active middle ear infection or a hole in the eardrum, because the pressure difference under water can make the injury considerably worse.

What can I safely do at home for the pain, and what must never go in my ear?

What can be done at home is limited: pain and fever relief suited to the person’s age and at the dose the doctor sets, a warm compress on the outside of the ear, sleeping with the head slightly raised to reduce pressure, plus rest and plenty of fluids. These make the pain easier to bear until the ear can be examined; they do not treat the cause of the infection, and they are no substitute for being seen if the illness does not improve or if any warning sign appears. A child should not be given any painkiller or fever medicine without the doctor knowing what suits their age and weight. Inside the ear itself, nothing at all goes in without an examination — no oils, no home remedies, no antiseptics, no cotton buds, and no drops without a prescription — and this matters most of all when there is discharge from the ear or any chance the eardrum is perforated. These are the things people most often try, and they do real harm:

Olive oil or any warmed oil.
Garlic, onion, lemon or any home remedy.
Hydrogen peroxide, alcohol or antiseptics.
Breast milk.
Cotton buds, or any object pushed into the ear to clean it.
Any ear drops without an examination and a prescription.

I am pregnant and I have a middle ear infection, what should I do?

A middle ear infection in pregnancy looks and feels exactly the same as at any other time; what changes is the medicine. Some painkillers and decongestants sold without a prescription are not suitable during pregnancy, and some are unsuitable only in particular months, so a pregnant woman should be examined and have whatever she takes prescribed by a doctor who has been told how many weeks pregnant she is — rather than treating herself, repeating an old prescription, or taking something that was prescribed for someone else. Beyond that, a blocked nose is very common in pregnancy because of hormonal changes and increased blood flow through the lining of the nose, and that congestion can reduce the ventilation the eustachian tube gives the ear, increasing both the blocked feeling and the chance of infection. A fever during pregnancy is in itself a reason to contact the doctor without delay. The same principle applies while breastfeeding: tell the doctor you are breastfeeding before any medicine is prescribed, because it changes what they choose.