Earache in Children: Causes, Home Care and Warning Signs

Earache is one of the leading complaints that take families to the emergency department in the middle of the night, and it often begins suddenly, at the least expected hour. The most important reason for this is anatomical: the Eustachian tube, which connects the middle ear to the back of the nose and allows it to ventilate, is shorter, narrower and more horizontal in children than in adults. This structure makes it easier for an infection in the nose and nasopharynx to reach the middle ear; after about the age of seven the position of the tube changes and the problem decreases by itself. Indeed, the great majority of children have at least one middle ear infection before the age of two, and some experience it repeatedly. The source of earache is not always the ear either; pain referred from the throat, teeth, jaw joint and lymph nodes can also be felt in the ear. In this article we look at why earache occurs in children, how to recognise it in babies who cannot yet speak, what should and must never be done at home, and which findings require a doctor to be seen without delay.

Why Does Earache Occur?

The most common cause of earache in children is middle ear infection, known in medicine as acute otitis media, and it usually appears a few days after a cold or influenza. During an upper respiratory tract infection the Eustachian tube swells and becomes blocked; the air in the middle ear is absorbed, fluid takes its place, and when this fluid becomes infected with bacteria, severe pain develops along with pressure behind the eardrum. The second most common cause is infection of the outer ear canal, popularly known as swimmer's ear; it develops in the swimming season when moisture remaining in the ear softens the skin and trauma such as a cotton bud is added. There is a practical way to tell these two conditions apart: in outer ear infection, touching the ear lobe or the small prominence in front of the ear causes marked pain, whereas in middle ear infection this manoeuvre generally does not increase the pain. In small children, foreign bodies such as beads, buttons, seeds or toy parts that get into the ear, and hardened earwax, also create pain and a feeling of fullness. The pressure difference arising during air travel or a change in altitude can cause sudden pain because it stretches the eardrum. Finally, teething periods, dental decay, inflammation of the tonsils and adenoids, pharyngitis, mumps and jaw joint problems can also create pain referred to the ear even though there is no disease in the ear itself.

How Is Earache Recognised in a Baby Who Cannot Speak?

The nought-to-two age group is the period in which ear infections are most common but diagnosis is most often delayed, because the child cannot describe the complaint. At this age the most reliable guide is the baby behaving differently from usual; restless crying with no apparent cause, intensifying at night in particular and increasing when lying down, is the most typical sign. Because sucking and swallowing change the pressure in the middle ear, the baby may have difficulty taking the breast or bottle and may let go and cry after a few sips; a sudden reluctance to feed is therefore an important clue. Constantly pulling or scratching the same ear, holding the head tilted to that side, or avoiding lying on the painful ear are also frequently seen behaviours; however, it should be remembered that ear-pulling alone is not diagnostic, as many babies do it out of habit. Fever, frequent waking during sleep, loss of appetite, nausea, vomiting and diarrhoea may accompany the picture; in some babies there is no fever at all. Yellow, green or bloody discharge from the ear shows that the eardrum has perforated because of pressure; in this case the pain usually eases suddenly, but a doctor must be consulted. In older children, returning to play shortly after saying their ear hurts leaves families uncertain; because these brief, recurring pains may point to fluid collecting in the middle ear, they should still be assessed.

What Can Be Done at Home?

The most valuable thing that can be done at home for earache is to bring the pain under proper control, because when the pain eases the child can both sleep and feed. Fever-reducing and pain-relieving medicines at the dose recommended by the physician and appropriate to the child's weight are used for this purpose; aspirin must never be given to children. Applying a warm compress wrapped in a towel over the painful ear is soothing, particularly where muscle tension and a feeling of pressure accompany the pain; some children benefit more from a cold application, so it is sensible to decide according to the child's response. Keeping the head slightly raised reduces the pressure that increases when lying down and so provides relief at night; babies should be fed in arms or at an angle of about forty-five degrees. If there is nasal congestion, applying saline on the physician's recommendation helps the Eustachian tube to ventilate and indirectly eases the pain. Adequate fluid intake supports Eustachian function by increasing swallowing and also prevents fluid loss during a feverish period. In older children, yawning, swallowing or chewing gum provides marked relief, especially in pressure pain related to air travel.

What Must Never Be Done at Home

Most of the mistakes made with earache arise from well-meaning but harmful home practices, chief among them putting drops into the ear. No drops should be used without the eardrum being examined with an otoscope to see whether it is intact; if the drum is perforated, the passage of drops into the middle ear can increase the pain and affect hearing. Instilling substances learned from the internet or from acquaintances — olive oil, garlic oil, onion juice, hydrogen peroxide and alcohol — is therefore inadvisable; these substances irritate the outer ear canal, make examination more difficult and may mask the infection. Cotton buds are another widespread error: rather than removing wax, the bud pushes it deeper into the narrow part of the canal, damages the skin and paves the way for outer ear infection. Trying to remove a foreign body from the ear at home is also a risky undertaking; the object may be pushed deeper, the eardrum may be perforated, and plant material may swell on contact with water and turn into something requiring surgery to remove. Stopping an antibiotic halfway once the fever or pain has passed is the point at which treatment is most often sabotaged; even if the child feels well, the period set by the physician must be completed. Ear irrigation while there is discharge or a perforated drum, entering a swimming pool, and letting water into the ear while bathing are likewise practices to be avoided.

When Should a Doctor Be Consulted Without Delay?

Every child with earache should be examined; but some situations require assessment without waiting for morning. In babies under six months, findings suggesting earache are always regarded as a priority, because infection can progress more quickly in this age group. Yellow, green, foul-smelling or bloody discharge from the ear, fever lasting more than three days or not coming down despite an appropriate fever reducer, and pain that becomes progressively more severe are likewise findings that allow no delay. Swelling, redness and tenderness behind the ear, and the ear lobe appearing pushed forward, is a serious sign that may indicate the infection has advanced into the bone behind the ear. Findings such as neck stiffness, persistent vomiting, excessive sleepiness, confusion, drooping on one side of the face or an inability to close the eyelid point to rare complications that require emergency assessment. Marked loss of balance, dizziness and falls in a child who can walk should likewise be investigated urgently. Apart from these, a child no longer responding to sounds as before, turning up the television, appearing distracted in class, or a pause in speech development requires assessment for fluid in the middle ear even in the absence of pain.

Diagnosis and Treatment

Diagnosis in earache rests on a detailed history and examination of the eardrum with an otoscope; by assessing the colour of the drum, whether it is bulging and how mobile it is, the physician determines whether there is inflammation in the middle ear. The same examination reveals whether the pain arises from the outer ear canal, a foreign body or earwax, or whether the ear is entirely sound and the pain is referred from another area; for this reason the throat, teeth and jaw joint are also examined routinely. If fluid in the middle ear is suspected, tympanometry, which measures the movement of the eardrum, and age-appropriate hearing tests clarify the picture. The first and unchanging step of treatment is relief of pain; the decision on antibiotics is made according to the child's age, the severity of the fever and findings, and whether one or both ears are affected. While antibiotics are usually started at once in children under two and in severe cases, in older children with mild illness the physician may prefer a short period of observation, because some middle ear infections are viral in origin and resolve by themselves. When an antibiotic is started, improvement is expected within the first two to three days; if there is no improvement despite this, the treatment needs to be reassessed. In frequently recurring infections, or in fluid collection that lasts for months and affects hearing, small ventilation tubes placed in the eardrum may come onto the agenda; these tubes usually fall out by themselves and restore hearing by returning the pressure in the middle ear to normal.

Reducing Recurrences

Some of the factors that increase the frequency of middle ear infections can be changed, and this is the most effective form of protection in recurring cases. Foremost among them is exposure to passive smoking; smoking at home or in the car is one of the strongest factors markedly raising a child's risk of ear infection. The way a baby is fed also has a direct effect: the risk of infection is lower in breastfed babies and higher in those fed by bottle, particularly lying flat. For this reason it is recommended that the baby be fed in arms or at an angle of about forty-five degrees, and that long feeds lying down late at night be avoided. In children with frequent upper respiratory infections, teaching hand hygiene, the habit of coughing into the elbow and not sharing personal items in crowded settings are simple but effective measures. Keeping the vaccination schedule complete provides protection against some of the agents that also cause middle ear infections. If there is allergic rhinitis, regular application of the treatment recommended by the physician supports Eustachian tube function by reducing nasal congestion. In the swimming season, keeping the ear dry after the pool and staying away from cotton buds reduces recurrences in children who have had outer ear infection.

Frequently Asked Questions

Does water getting into the ear in the bath cause middle ear infection? An intact eardrum does not allow water from the outer ear canal to pass into the middle ear; bath water is therefore not a cause of middle ear infection. Middle ear infection develops not from water entering from outside but from infection travelling from the nasopharynx along the Eustachian tube. By contrast, moisture remaining in the ear is a genuine risk for outer ear canal infection. The situation is different if there is a perforation or a tube in the eardrum; in these children protection from water is planned according to the physician's advice.

Are antibiotics needed for every earache? No. A significant proportion of middle ear infections are viral in origin and resolve by themselves; in these cases what is really needed is proper pain control. The decision on antibiotics is made by assessing the child's age, the severity of the fever and findings, and the examination findings together. In small babies and in severe cases, however, treatment is usually started without delay.

Can I stop the antibiotic if the pain has gone? It should not be stopped. A reduction in pain does not mean the infection has been completely cleared; bacteria surviving in the middle ear can cause the condition to flare up again within a short time. When the period set by the physician is not completed, the risk of recurrent infection and resistance increases. The decision on duration and dose always rests with the physician.

Does earache leave hearing loss? In the acute period, a temporary reduction in hearing due to fluid in the middle ear is expected and improves as the inflammation subsides. However, if the fluid collection lasts for weeks or sometimes months, the hearing loss continues and can affect speech development in young children. For this reason follow-up after infection should not be neglected, and a hearing test should be carried out if necessary. With appropriate follow-up and tube placement where needed, this picture is largely reversible.

My child said "my ear hurts" and went straight back to playing — should I take it seriously? This is the situation about which families hesitate most, and it should not be ignored. Brief, passing earaches often point to a ventilation problem in the middle ear or to fluid collecting behind the drum. In this case there may be no fever and no obvious illness, but hearing may be quietly affected. If the pain recurs, having the ear examined is the right approach.

This article has been prepared for general information purposes only and does not take the place of a medical examination. If you notice earache, discharge from the ear, fever or any change in hearing in your child, please attend a healthcare facility for assessment, diagnosis and treatment.