Ear Infections: Causes, Types, and When to Seek Help
Ear infections and earwax impaction share several symptoms, which makes distinguishing between them important. Getting the wrong treatment — or delaying the right one — can make things significantly worse.
The Two Main Types of Ear Infection
Ear infections are classified by where they occur. Otitis externa affects the outer ear canal — the passage between the outer ear and the eardrum. Otitis media affects the middle ear — the space behind the eardrum. They have different causes, different symptoms, and different treatments. Knowing which you're dealing with matters.
Otitis Externa (Outer Ear Infection)
Otitis externa is an infection of the ear canal skin, most commonly caused by bacteria — particularly Pseudomonas aeruginosa and Staphylococcus aureus. It's sometimes called swimmer's ear because water exposure is a major risk factor — the moist environment of a wet ear canal is ideal for bacterial growth.
The hallmark symptom of otitis externa is pain that worsens when the outer ear is pulled or pressed. This distinguishes it from middle ear infection, where pulling the ear doesn't change the pain. Other symptoms include itching, redness and swelling of the canal, discharge (which may be clear, yellow, or green), and partial hearing loss if the swelling is significant.
Risk factors include frequent swimming, use of cotton buds (which scratch the canal skin), hearing aid use, eczema or psoriasis affecting the canal, and excessive ear cleaning. Treatment is with antibiotic or antifungal ear drops, prescribed by a GP. Oral antibiotics are rarely needed unless the infection has spread beyond the canal.
Otitis Media (Middle Ear Infection)
Otitis media is an infection of the middle ear, most commonly caused by bacteria or viruses that travel from the throat via the Eustachian tube. It's more common in children than adults, and often follows a cold or upper respiratory infection. The Eustachian tube in children is shorter and more horizontal than in adults, making it easier for pathogens to travel from the throat to the middle ear.
Symptoms include deep ear pain, a feeling of fullness or pressure, muffled hearing, and often fever. In children, ear pulling, irritability, and disturbed sleep are common signs. If the eardrum perforates — which can happen when pressure builds up — there may be a sudden relief of pain followed by discharge from the ear.
Most cases of acute otitis media in adults and older children resolve without antibiotics. NICE guidelines recommend a "watchful waiting" approach for 72 hours in most cases, with antibiotics reserved for those who don't improve, have severe symptoms, or are at higher risk. Paracetamol or ibuprofen for pain relief is appropriate while waiting.
Earwax vs Infection: How to Tell the Difference
The overlap in symptoms between earwax impaction and ear infection is significant — both can cause hearing loss, ear fullness, and discomfort. But there are distinguishing features that help clarify the picture.
| Feature | Earwax Impaction | Ear Infection |
|---|---|---|
| Onset | Gradual, over days to weeks | Often sudden, may follow a cold |
| Pain | Mild discomfort or pressure; rarely significant pain | Often significant; worsens with ear pulling (otitis externa) or deep ache (otitis media) |
| Fever | Not present | Common, particularly in otitis media |
| Discharge | Not present | Common in otitis externa; may occur if eardrum perforates |
| Hearing loss | Gradual, conductive | May be present; often accompanied by other symptoms |
| Response to drops | Improves with olive oil drops | Drops do not resolve infection; may worsen pain |
| Who to see | Private ear care specialist | GP for assessment and prescription treatment |
If you're unsure whether your symptoms are caused by wax or infection, the safest approach is to see a GP for an initial assessment. Wax removal should not be performed in the presence of an active infection — the ear needs to be clear of infection before any removal procedure is appropriate.
The Relationship Between Earwax and Infection
Earwax and ear infections are related in both directions. Wax impaction can create conditions that favour infection — a blocked canal retains moisture and debris, providing an environment for bacterial growth. Conversely, the inflammation and swelling caused by an infection can prevent normal wax migration, leading to accumulation after the infection resolves.
Cotton bud use is a common link between the two — it both compacts wax and scratches the canal skin, creating entry points for bacteria. People who use cotton buds regularly are at higher risk of both impaction and otitis externa.
After an ear infection has fully resolved, it's worth having your ears checked for wax accumulation, particularly if you experienced hearing loss during the infection. Residual wax that wasn't migrating normally during the infection may now need professional removal.
When to Go to A&E Rather Than Your GP
Most ear infections can wait for a GP appointment. But some presentations require urgent assessment. Go to A&E or call 999 if you have: sudden, severe hearing loss that came on very rapidly; significant facial weakness or asymmetry on the same side as the ear problem; severe dizziness with nausea and vomiting that prevents you from standing; or signs of mastoiditis — swelling, redness, and tenderness behind the ear, with the ear pushed forward.
Mastoiditis is a rare but serious complication of untreated middle ear infection, in which the infection spreads to the mastoid bone behind the ear. It requires urgent hospital treatment. The symptoms are distinctive — the combination of ear pain, swelling behind the ear, and a protruding ear is not a presentation to wait on.
Written & Reviewed By
Eleni Kiromitis
Ear Care Specialist — Earwax Removal Devon
Eleni is a qualified ear care practitioner based in South Molton, Devon. She holds a Certificate in Ear Care (Level 6) and is trained in both microsuction and water irrigation. She practises in line with NICE guideline NG207 on earwax management and carries full professional indemnity insurance. All clinical content on this page has been written and reviewed by Eleni to ensure accuracy.