The most common symptoms of an ear infection are ear pain, fever, and difficulty hearing. In young children who can’t describe what they feel, you’ll often notice irritability, trouble sleeping, and tugging at the ear. The specific symptoms depend on whether the infection is in the middle ear (behind the eardrum) or the outer ear canal, and how severe it’s become.
Middle Ear Infection Symptoms
Middle ear infections are the type most people mean when they say “ear infection,” and they’re especially common in children. The hallmark symptom is a sharp or throbbing pain deep inside the ear, caused by fluid and pressure building up behind the eardrum. This pain often gets worse when lying down, which is why ear infections tend to disrupt sleep more than daytime activity.
Fever frequently accompanies a middle ear infection, though not always. You may also notice muffled hearing or a feeling of fullness in the affected ear, since fluid trapped behind the eardrum interferes with how sound travels. In some cases, the pressure builds enough to create a small hole in the eardrum, and you’ll see pus or fluid draining from the ear. That drainage actually tends to relieve the pain, since the pressure drops once the fluid has a way out.
Signs in Babies and Toddlers
Young children get ear infections far more often than adults, but they can’t tell you what hurts. According to the National Institute on Deafness and Other Communication Disorders, the behavioral signs to watch for include:
- Tugging or pulling at one or both ears
- Unusual fussiness and crying, especially when lying down
- Trouble sleeping or waking up more frequently at night
- Balance problems or clumsiness
- Reduced response to quiet sounds
Feeding changes are another clue. Swallowing and chewing can shift pressure in the middle ear, making sucking on a bottle or breastfeeding painful. If your baby suddenly refuses to eat and seems uncomfortable, an ear infection is a common culprit. Fever in infants under 3 months, even a relatively low one at 100.4°F or above, is always worth a call to your pediatrician regardless of the suspected cause.
Outer Ear Infection Symptoms
Outer ear infections, sometimes called swimmer’s ear, affect the ear canal rather than the space behind the eardrum. The symptoms feel different. The ear canal itches first, then becomes increasingly painful. The skin inside the canal turns red and swollen, and you may see flaky skin debris or pus.
The key way to tell an outer ear infection apart from a middle ear infection is the pain trigger. With an outer ear infection, pulling on the earlobe or pressing on the small flap at the front of the ear (the tragus) makes the pain noticeably worse. Middle ear infections don’t respond to external touch in the same way. Outer ear infections also tend to produce more visible drainage and canal swelling, while middle ear infections center on deeper pressure and fever.
How Long Symptoms Last
Most middle ear infections improve within two to three days, whether or not antibiotics are used. When antibiotics are prescribed, fever typically breaks within 48 hours, and ear pain eases significantly by day two and resolves by day three. For mild infections in children over age two, doctors sometimes recommend a “watchful waiting” approach, since many of these infections are viral and clear on their own.
If symptoms haven’t improved after two to three days, or if they’re getting worse instead of better, that’s a sign the infection may need a different treatment approach. Persistent fluid behind the eardrum can linger for weeks or even months after the infection itself has cleared, causing ongoing muffled hearing even when the pain and fever are long gone. This fluid usually resolves on its own, but repeated or prolonged cases may need further evaluation.
When Symptoms Signal Something Serious
Most ear infections are straightforward, but certain symptoms point to complications that need prompt attention. The CDC recommends seeking care if you or your child has:
- A fever of 102.2°F (39°C) or higher
- Pus or fluid draining from the ear
- Symptoms lasting more than two to three days
- Symptoms that worsen after initially improving
- Noticeable hearing loss
Rarely, a middle ear infection can spread to the bone behind the ear, a condition called mastoiditis. The warning signs are swelling, redness, warmth, and tenderness in the area directly behind the ear, sometimes pushing the outer ear forward and away from the head. High fever accompanies this. Mastoiditis requires medical treatment and shouldn’t be managed at home.
Even more rarely, infection can spread toward the brain. Severe headaches, neck stiffness, seizures, or confusion after an ear infection are emergency symptoms. These intracranial complications occur in a small percentage of mastoiditis cases, but recognizing them early makes a significant difference in outcomes.
What a Doctor Looks For
When you bring a child in for a suspected ear infection, the doctor uses a small lighted instrument called an otoscope to examine the eardrum. A healthy eardrum is translucent and moves freely when air is puffed against it. With a middle ear infection, the eardrum typically bulges outward from the fluid pressure behind it, and its movement is reduced or absent. It may appear red, though redness alone isn’t enough for a diagnosis, since crying can also make the eardrum look red.
The diagnostic guidelines from the American Academy of Pediatrics require either moderate to severe bulging of the eardrum, new drainage not caused by an outer ear infection, or mild bulging combined with recent ear pain or redness. This means doctors are looking for a combination of what they see and what you describe. Being specific about when symptoms started, which ear hurts, and whether there’s been any drainage helps them make an accurate call.