Ear infections typically announce themselves with a sharp or throbbing pain deep inside the ear, often alongside muffled hearing and a feeling of fullness or pressure. But the specific signs depend on which part of the ear is affected, and in babies or toddlers, the clues can be entirely behavioral. Here’s how to tell what’s going on.
The Core Symptoms in Adults and Older Children
The hallmark of a middle ear infection is pain that builds quickly, often within hours. It usually shows up during or right after a cold or upper respiratory illness. Along with the pain, you may notice that sounds seem quieter or distant on the affected side. Fluid trapped behind the eardrum is the reason: the average hearing reduction is about 24 decibels, roughly equivalent to wearing earplugs. If the fluid is thick, hearing loss can reach 45 decibels, which is enough to make normal conversation hard to follow.
Other common symptoms include a feeling of pressure or fullness in the ear, low-grade fever, and sometimes fluid draining from the ear canal. That drainage can signal that the eardrum has ruptured under pressure. Counterintuitively, a ruptured eardrum often brings sudden pain relief because the pressure drops. The fluid may look like pus or contain streaks of blood. Most small perforations heal on their own within a few weeks.
How to Spot an Ear Infection in Babies and Toddlers
Young children can’t describe ear pain, so you have to read behavior instead. The most reliable signs are tugging, rubbing, or pulling at one or both ears, combined with unusual fussiness or irritability that doesn’t have another obvious cause. A child with an ear infection may also have trouble sleeping, refuse to eat (swallowing changes pressure in the middle ear, which hurts), or seem less responsive to sounds than usual. Fever is common but not universal.
These signs carry more weight if they appear during or shortly after a cold. Upper respiratory infections cause swelling that blocks the narrow tubes connecting the throat to the middle ear, trapping fluid and bacteria behind the eardrum. In small children, those tubes are shorter and more horizontal, which is why ear infections are so much more common in kids than in adults.
Outer Ear vs. Middle Ear Infections
Not all ear infections are the same, and telling the two main types apart helps you understand what you’re dealing with.
A middle ear infection (otitis media) sits behind the eardrum. It usually follows a cold, produces a deep ache or pressure, and may cause muffled hearing or fever. You can’t see much from the outside. A doctor diagnoses it by looking at the eardrum with a small lighted scope: a bulging, red, or cloudy eardrum with fluid behind it confirms the infection.
An outer ear infection (otitis externa, sometimes called swimmer’s ear) affects the ear canal itself. The giveaway is pain when you pull on your outer ear or press the small flap of cartilage in front of the ear canal. That traction test is one of the simplest ways to distinguish the two types at home. Outer ear infections also tend to cause visible redness and swelling around the canal opening, sometimes with a watery or yellowish discharge. They’re strongly associated with swimming or getting water trapped in the ear.
What a Doctor Looks For
Diagnosing a middle ear infection requires more than just symptoms. Current guidelines say the diagnosis should be made when a doctor sees moderate to severe bulging of the eardrum, or new drainage from the ear that isn’t caused by an outer ear infection. It can also be diagnosed when the eardrum shows mild bulging along with ear pain that started within the past 48 hours, especially if the eardrum is intensely red. Importantly, if there’s no fluid behind the eardrum, the diagnosis shouldn’t be made, even if the ear hurts.
Doctors sometimes use a small puff of air (pneumatic otoscopy) to see how the eardrum moves. A healthy eardrum flexes easily. One backed by trapped fluid barely moves at all. In some cases, a tympanometry test measures eardrum movement more precisely.
When the Infection Spreads Deeper
Occasionally, a middle ear infection can spread to the inner ear, causing a condition called labyrinthitis. The main warning sign is vertigo: a sudden sensation that the room is spinning, often with nausea and more significant hearing loss. This is different from the mild unsteadiness some people feel with a plugged ear. Labyrinthitis symptoms tend to come on suddenly and can be intense enough to make standing or walking difficult.
A more serious complication is mastoiditis, where infection spreads into the bone behind the ear. Signs include throbbing ear pain that won’t let up, swelling or redness behind the ear, skin that feels doughy or soft over the bone, pus-like drainage, worsening hearing loss, fever, and headache. In some cases the affected ear visibly sticks out further than the other one. Confusion, double vision, or vertigo alongside these symptoms signals a need for immediate medical attention. In very young children, the main clues are persistent ear-pulling combined with unusual lethargy or fussiness.
Signs That Point Away From Infection
Ear pain doesn’t always mean infection. Jaw clenching or teeth grinding can refer pain into the ear. So can sinus congestion, a sore throat, or a dental problem on the same side. If your ear hurts but you have no fever, no hearing changes, no recent cold, and no pain when you press or tug the outer ear, the source may be somewhere else entirely. Pain that worsens with chewing, for instance, often traces back to the jaw joint rather than the ear.
Fluid behind the eardrum without infection (called an effusion) can also cause muffled hearing and pressure. This sometimes lingers for weeks after a cold resolves and typically clears on its own without antibiotics.