What is the difference between middle ear and outer ear infection?

The middle ear sits behind the ear drum and connects to the back of the nose via the Eustachian tube. Middle ear infection (acute otitis media) usually follows a viral cold and causes deep ear pain, fever, and sometimes reduced hearing. The outer ear is the canal between the ear drum and the outside. Outer ear infection (otitis externa, or swimmer's ear) typically follows water exposure or cotton bud trauma and causes pain when the outer ear is pulled or pressed, often with itching, discharge, or swelling of the canal. A GP can distinguish them with otoscopy — looking inside the ear with a lighted instrument.

Do ear infections need antibiotics?

Most middle ear infections in otherwise well children do not need antibiotics. Around 80 percent are triggered by viruses, and most settle within one to three days with simple pain relief. Australian guidelines reserve antibiotics for specific situations: infants under six months, children aged six to 24 months with both ears affected, severe symptoms, perforated ear drum with discharge, Aboriginal and Torres Strait Islander children (where chronic ear disease is more common), people with weakened immunity, and any case not improving at 48 to 72 hours. Outer ear infections, by contrast, are usually treated with topical antibiotic and steroid ear drops rather than oral antibiotics.

How long does an ear infection last?

Most middle ear infections improve within 24 to 72 hours and resolve within a week. Fluid behind the ear drum (called glue ear or otitis media with effusion) can persist for several weeks after the acute infection, which is why hearing may still feel muffled for a while. Outer ear infections usually settle within five to seven days of starting ear drops and keeping water out of the ear. If symptoms persist beyond these windows, a review with a GP is appropriate to check for complications or alternative diagnoses.

What helps ear pain at home?

Paracetamol or ibuprofen at age-appropriate doses are first-line for pain relief. A warm (not hot) compress over the affected ear can help comfort. For outer ear infection, keeping the ear dry — no swimming, careful showering with a cotton ball coated in petroleum jelly to plug the canal — supports healing. Do not put cotton buds, hair pins, or any object into the ear canal: this is one of the most common causes of recurrent outer ear infection and can damage the ear drum. Home remedies such as garlic or herbal ear drops are not recommended and can be dangerous if the ear drum is perforated.

When should I see a GP about an ear infection?

See a GP if ear pain is severe, there is fluid or pus draining from the ear, hearing is noticeably reduced, fever is high or persistent, or symptoms have not improved within 48 to 72 hours of starting simple pain relief. Seek urgent care or attend an emergency department for any red flag: swelling, redness or tenderness behind the ear (possible mastoiditis), facial weakness or drooping, severe dizziness with vomiting, severe headache or neck stiffness, or symptoms in a baby under six months of age. Adults with diabetes or weakened immunity who develop severe ear pain should also seek prompt assessment, as a serious form of outer ear infection called malignant otitis externa needs urgent specialist care.

How can I prevent ear infections?

Several practical steps reduce risk. Stay up to date with childhood vaccinations — pneumococcal (Prevenar), Hib, and annual influenza protect against bacteria and viruses that cause middle ear infection. Avoid exposing children to tobacco smoke, which significantly increases otitis media risk. Breastfeed for at least six months where possible. Manage allergic rhinitis (hayfever), which contributes to Eustachian tube dysfunction. For outer ear infection prevention: dry the ears thoroughly after swimming or showering, avoid cotton buds, and consider ear-drying drops (such as those containing alcohol or acetic acid) if you swim regularly and have had recurrent swimmer's ear.

Acute otitis media and otitis externa

Ear infections (otitis media and externa): what to do and when to see a GP

By Dr HB Lo, FACRRM Reviewed 2 June 2026 8 min read

Acute otitis media is a middle ear infection, common in young children, causing ear pain and sometimes fever. Most cases follow a viral cold and settle within one to three days with paracetamol or ibuprofen. Antibiotics are reserved for infants, severe symptoms, ear drum perforation, Aboriginal and Torres Strait Islander children, or no improvement at 48 to 72 hours.

Otitis externa (swimmer's ear) is ear canal infection, often after water exposure. It needs gentle cleaning and antibiotic-steroid drops. See a GP if pain is severe, hearing drops, or red flags appear such as swelling behind the ear or facial weakness.

Two different ear infections, often confused

Ear infections fall into two main groups that get muddled in everyday language. The treatment, the timeline, and the at-home steps differ, so the distinction matters.

Acute otitis media is infection of the middle ear — the space behind the ear drum that connects to the back of the nose via the Eustachian tube. It is very common in young children: around 80 percent have at least one episode by age three. It usually follows a viral cold, when fluid and inflammation build up behind the ear drum and sometimes become superinfected with bacteria. Symptoms include deep ear pain, fever, irritability in young children, and sometimes reduced hearing. In a small number of cases the ear drum perforates and pus drains from the ear — this often relieves the pain.

Otitis externa, also known as swimmer’s ear, is infection of the ear canal — the outer tube between the ear drum and the outside world. It is most often caused by bacteria (commonly Pseudomonas or Staph aureus) and sometimes by fungi. Risk factors include water exposure (swimming, sweating, humid climates), cotton bud or hairpin trauma, eczema affecting the canal skin, hearing aid use, and a narrow ear canal. Pain is the dominant symptom — characteristically worse when you press on the small bump in front of the ear (the tragus) or pull on the outer ear. Itching, discharge, and a sensation of blocked hearing are common.

A GP can usually tell them apart by looking inside the ear with an otoscope. In acute otitis media the ear drum looks red, bulging, and moves poorly. In otitis externa the canal itself is swollen, often filled with debris or pus, and the ear drum (if visible) may look normal.

What causes them

Middle ear infection almost always begins with a viral upper respiratory infection — a common cold. The Eustachian tube, which normally drains fluid from the middle ear and equalises pressure, becomes blocked by swelling. Fluid accumulates behind the ear drum and can become infected by bacteria that travel from the back of the nose. The most common bacterial culprits in Australia are Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pyogenes. Risk factors include young age, attendance at childcare, passive smoke exposure, bottle feeding, family history, and allergic rhinitis.

Outer ear infection has different triggers. Anything that disrupts the protective barrier of the canal skin allows bacteria or fungi to take hold: water trapped after swimming, cotton bud trauma, skin conditions such as eczema or psoriasis affecting the canal, and the warm humid microclimate created by hearing aids or in-ear headphones. Cotton buds deserve a particular call-out — they strip the protective wax layer, push debris deeper into the canal, and cause microtrauma that allows infection. Avoiding them is one of the single most effective prevention steps.

How a GP makes the diagnosis

Diagnosis in general practice is usually clinical, based on history and examination with an otoscope. There is no routine blood test or scan required for uncomplicated cases. The GP will ask about timing, pain, fever, discharge, hearing changes, recent water exposure, prior episodes, and risk factors. Otoscopy directly visualises the ear drum and canal. Sometimes a pneumatic otoscope (which puffs air) is used to assess ear drum movement, or a tympanometer to measure middle ear pressure. Per the Royal Children’s Hospital clinical practice guideline, bulging of the ear drum with reduced mobility is the most specific finding for acute otitis media.

Ear swabs are not routine but are useful in chronic, recurrent, or refractory cases, in people with weakened immunity, or when the ear is discharging. Formal hearing assessment (audiometry) and tympanometry may be requested if hearing concerns persist beyond an acute infection, or for recurrent cases. Imaging (CT or MRI) is reserved for suspected complications and is arranged by a specialist.

Treatment of middle ear infection

The current AU guideline-supported default for most acute otitis media in otherwise well children is watchful waiting plus good pain relief — not immediate antibiotics. Most cases resolve within 24 to 72 hours regardless of whether antibiotics are given, and unnecessary antibiotic use contributes to side effects (rash, diarrhoea, thrush) and to broader antibiotic resistance.

The cornerstone of management is paracetamol or ibuprofen at age-appropriate doses for pain and fever. Fluids and rest support recovery. A review in 48 to 72 hours, or sooner if symptoms worsen, allows the GP to reassess.

Antibiotics are clearly indicated, per Therapeutic Guidelines and the Royal Children’s Hospital guideline, in specific situations:

Infants under six months of age
Children six to 24 months with both ears affected
Severe symptoms (high fever, severe pain, very unwell)
Perforated ear drum with active discharge
No improvement at 48 to 72 hours of watchful waiting
People with weakened immune systems
Aboriginal and Torres Strait Islander children, where the risk of chronic ear infection and lasting hearing loss is higher — the RACGP guidance and the Australian Healthy Skin Consortium both endorse a lower threshold for treatment in this group

Amoxicillin is the standard first-line antibiotic when one is indicated. Specific doses, alternatives for penicillin allergy, and duration are matters for the prescribing GP based on the individual situation and the Australian Medicines Handbook.

Treatment of outer ear infection

Outer ear infection (swimmer’s ear) is treated differently. The two pillars are gentle cleaning of the canal and topical ear drops.

Cleaning removes debris and pus so that ear drops can reach the inflamed skin. Mild cases can be cleaned by the GP using gentle suction or a dry mop on a small cotton-wool carrier. More extensive debris is best handled by an ENT specialist. Patients should not attempt to clean the canal with cotton buds at home — this is exactly the trauma that often triggered the infection.

Ear drops combine an antibiotic with a steroid to reduce both the infection and the inflammation. The choice of drops depends on whether the ear drum is intact or perforated, on whether a fungal cause is suspected, and on patient factors. The Therapeutic Guidelines recommend specific topical preparations; aminoglycoside-containing drops (such as those with framycetin or neomycin) are avoided if the ear drum is perforated because they can damage the inner ear (a small risk of hearing loss). When perforation is possible, ciprofloxacin-based drops are preferred.

Oral antibiotics are not routinely needed for swimmer’s ear and are reserved for cases where infection has spread beyond the canal into the surrounding skin, or where the person has weakened immunity.

Keep water out of the affected ear during treatment — no swimming, and use a petroleum-jelly-coated cotton ball in the outer ear while showering. Most cases settle in five to seven days.

Practical at-home advice

For both types of ear infection, several simple measures help:

Use paracetamol or ibuprofen for pain and fever at appropriate doses
Rest and fluids
For middle ear infection: a warm compress over the ear can comfort a child
For outer ear infection: keep water out, avoid cotton buds, use ear-drying drops if you swim regularly and have had recurrent episodes
Do not put anything into the ear canal — no cotton buds, hairpins, or homemade remedies
Avoid herbal or essential-oil ear drops, particularly if the ear drum could be perforated

For Australian consumer-friendly background reading, HealthDirect’s ear infection page, HealthDirect’s swimmer’s ear page, and the Better Health Channel all provide reliable information.

When to see a GP — and when it is urgent

See a GP within a day or two if:

Ear pain is moderate to severe and not controlled by paracetamol or ibuprofen
Fluid or pus is draining from the ear
Hearing is noticeably reduced
Fever is high or persistent
Symptoms have not improved in 48 to 72 hours
The person affected is an infant under six months
The person is an Aboriginal or Torres Strait Islander child
The person has diabetes or a weakened immune system
Episodes are recurrent (three or more in six months, or four or more in twelve months) — a referral to an ear, nose and throat (ENT) specialist may be warranted, sometimes for consideration of grommets (tiny tubes inserted into the ear drum to help drain fluid)

Attend an emergency department or call 000 for any of these red flags:

Swelling, redness, or tenderness behind the ear, especially with fever — this may indicate mastoiditis, a serious infection of the bone behind the ear
Facial weakness or drooping on the side of the affected ear
Severe dizziness with vomiting or trouble walking
Severe headache, neck stiffness, drowsiness, or confusion — possible spread of infection to the lining around the brain
Severe ear pain in an adult with diabetes or weakened immunity — possible malignant (necrotising) otitis externa, which needs urgent specialist assessment
Foreign body in a child’s ear that you cannot easily remove — do not push it deeper; have it removed safely

Persistent fluid behind the ear drum after an acute episode — called glue ear or otitis media with effusion — can affect hearing and, in young children, speech and learning. A GP review and, where needed, formal hearing assessment via an audiologist or Australian Hearing Services helps detect and manage this.

What this article is and is not

This is general health information based on current Australian clinical guidelines — Therapeutic Guidelines (eTG complete), the Royal Children’s Hospital clinical practice guideline, RACGP guidance on otitis media in Aboriginal and Torres Strait Islander populations, the Australian Healthy Skin Consortium, and the Australian Medicines Handbook. It is not personal medical advice and does not replace a consultation with your own GP. If you or someone you care for has an ear infection that is worrying you, see your GP or attend a clinic for a proper assessment, especially if any of the warning signs above apply.

Sources cited

Frequently asked questions

What is the difference between middle ear and outer ear infection?

The middle ear sits behind the ear drum and connects to the back of the nose via the Eustachian tube. Middle ear infection (acute otitis media) usually follows a viral cold and causes deep ear pain, fever, and sometimes reduced hearing. The outer ear is the canal between the ear drum and the outside. Outer ear infection (otitis externa, or swimmer's ear) typically follows water exposure or cotton bud trauma and causes pain when the outer ear is pulled or pressed, often with itching, discharge, or swelling of the canal. A GP can distinguish them with otoscopy — looking inside the ear with a lighted instrument.
Do ear infections need antibiotics?

Most middle ear infections in otherwise well children do not need antibiotics. Around 80 percent are triggered by viruses, and most settle within one to three days with simple pain relief. Australian guidelines reserve antibiotics for specific situations: infants under six months, children aged six to 24 months with both ears affected, severe symptoms, perforated ear drum with discharge, Aboriginal and Torres Strait Islander children (where chronic ear disease is more common), people with weakened immunity, and any case not improving at 48 to 72 hours. Outer ear infections, by contrast, are usually treated with topical antibiotic and steroid ear drops rather than oral antibiotics.
How long does an ear infection last?

Most middle ear infections improve within 24 to 72 hours and resolve within a week. Fluid behind the ear drum (called glue ear or otitis media with effusion) can persist for several weeks after the acute infection, which is why hearing may still feel muffled for a while. Outer ear infections usually settle within five to seven days of starting ear drops and keeping water out of the ear. If symptoms persist beyond these windows, a review with a GP is appropriate to check for complications or alternative diagnoses.
What helps ear pain at home?

Paracetamol or ibuprofen at age-appropriate doses are first-line for pain relief. A warm (not hot) compress over the affected ear can help comfort. For outer ear infection, keeping the ear dry — no swimming, careful showering with a cotton ball coated in petroleum jelly to plug the canal — supports healing. Do not put cotton buds, hair pins, or any object into the ear canal: this is one of the most common causes of recurrent outer ear infection and can damage the ear drum. Home remedies such as garlic or herbal ear drops are not recommended and can be dangerous if the ear drum is perforated.
When should I see a GP about an ear infection?

See a GP if ear pain is severe, there is fluid or pus draining from the ear, hearing is noticeably reduced, fever is high or persistent, or symptoms have not improved within 48 to 72 hours of starting simple pain relief. Seek urgent care or attend an emergency department for any red flag: swelling, redness or tenderness behind the ear (possible mastoiditis), facial weakness or drooping, severe dizziness with vomiting, severe headache or neck stiffness, or symptoms in a baby under six months of age. Adults with diabetes or weakened immunity who develop severe ear pain should also seek prompt assessment, as a serious form of outer ear infection called malignant otitis externa needs urgent specialist care.
How can I prevent ear infections?

Several practical steps reduce risk. Stay up to date with childhood vaccinations — pneumococcal (Prevenar), Hib, and annual influenza protect against bacteria and viruses that cause middle ear infection. Avoid exposing children to tobacco smoke, which significantly increases otitis media risk. Breastfeed for at least six months where possible. Manage allergic rhinitis (hayfever), which contributes to Eustachian tube dysfunction. For outer ear infection prevention: dry the ears thoroughly after swimming or showering, avoid cotton buds, and consider ear-drying drops (such as those containing alcohol or acetic acid) if you swim regularly and have had recurrent swimmer's ear.

Source quality

Sources grouped by evidence tier. AU primary tier first; international where AU is silent or lagging; named-author reconstruction where guidelines have not yet caught up. How tiers work.

T1 AU primary 9 sources