Ear Pain in Adults: The Causes That Are Not an Ear Infection, and the One Sign That Needs a Specialist

An adult with earache usually assumes it is an ear infection and often gets handed an antibiotic. In a good share of cases both the assumption and the antibiotic are wrong, and the reason is worth understanding: in adults, the ear is frequently not where the problem is.

Children get middle ear infections because their drainage tubes are short, soft and horizontal. Adult tubes are longer and steeper, so middle ear infection becomes much less common. What takes its place is a different list.

👍 Outer ear: the commonest one

Infection of the ear canal skin, called otitis externa and widely known as swimmer ear, is the leading cause of ear pain in adults. The canal is a warm, narrow, dead-ended tube lined with thin skin, and once that skin is damaged or waterlogged, bacteria do well there.

What sets it off is reliably one of a short list: water that stays in after swimming or showering, cotton buds, in-ear headphones worn for hours, hearing aids, hot humid weather, and skin conditions like eczema or psoriasis affecting the canal.

Keeping it dry matters more than most people expect. No swimming while it is active, and in the shower a plug of cotton wool with a smear of petroleum jelly on the outer surface keeps water out better than cotton wool alone.

🍄 When it is fungus instead

Worth knowing because the treatment is the opposite of what people reach for. Repeated or prolonged courses of antibiotic ear drops clear the normal bacteria and let fungus take over the canal.

• 🚨 Itching out of proportion to the pain is the signature — often maddening rather than sore
• 🔍 Debris that looks like wet paper, cotton wool or black specks
• ❌ More antibiotic drops make it worse. It needs an antifungal and thorough cleaning
• 📅 It is slower to clear than the bacterial kind and often needs the canal cleaned more than once

If a canal infection has not responded to two courses of antibiotic drops, this is the first thing to ask about rather than trying a third.

🚨 The serious form, mostly in diabetes

Rare, and the reason severe canal infection in an older adult is taken seriously rather than treated by text message.

Necrotising otitis externa is infection that spreads from the canal into the bone at the base of the skull. It occurs almost entirely in people with diabetes, especially poorly controlled, and in those with weakened immunity.

This is the one situation where an oral antibiotic is the centre of treating an outer ear infection, and Cipro (Ciprofloxacin) is the usual choice because of the organism involved. It is a hospital-supervised course, not a prescription to self-manage.

🦻 Middle ear infection in an adult

Less common than in children, and it tends to follow a cold, a bout of allergic rhinitis, or nasal blockage. The pattern differs from canal infection: pain is deep and throbbing, touching the ear does not make it worse, hearing is dulled, and there may be fever.

When it is genuinely bacterial, this is where an antibiotic earns its place.

Children are a different calculation, with watchful waiting playing a much larger role — covered in our guide to ear infection in children and which antibiotic is used. For ears that keep going wrong, or fluid that will not clear, see chronic ear infection, glue ear and grommets.

🦷 When the ear is fine and the pain is real

A large share of adults with earache have an ear that looks completely normal on examination. The pain is genuine; it is arriving from somewhere else along shared nerves.

• 🦷 The jaw joint. Probably the single commonest cause of earache with a normal ear. Pain in front of the ear, worse when chewing or first thing in the morning, often with clicking and with tooth grinding at night. The joint sits directly against the ear canal
• 🦷 Teeth, especially lower back molars and wisdom teeth. A dying tooth can present as pure earache with no tooth pain at all
• 🗣️ Throat and tonsils. Tonsillitis refers to the ear through a shared nerve. Sore throat plus one-sided ear pain plus difficulty opening the mouth suggests an abscess beside the tonsil, which needs same-day assessment — see tonsillitis and how it is treated
• 💇 The neck. Upper cervical spine problems and muscle tension refer upward into the ear
• ⚡ Nerve pain. Brief electric-shock pains lasting seconds, triggered by swallowing or touching a spot, suggest neuralgia rather than infection
• 💧 Eustachian tube trouble. After a cold or a flight: blocked, full, popping, muffled hearing, more pressure than pain. An antibiotic does nothing for this. If it keeps recurring, allergy may be the driver — see allergic rhinitis
• ✈️ Barotrauma from flying or diving, worst on descent, settling over days
• 🧹 Wax. Rarely painful on its own, but impacted wax that gets wet swells and can press against the drum

🚨 The sign that changes everything

🦠 Shingles in the ear, and the 72-hour window

Easy to miss early and worth recognising, because the timing of treatment decides the result.

The chickenpox virus can reactivate in the nerve supplying the ear. This produces severe one-sided ear pain, often before any rash appears, followed by blisters in the ear canal, on the outer ear or in the mouth on that side.

• 😠 Pain first, sometimes for a day or two with nothing to see — which is when it gets called an ear infection
• 🫤 Weakness of one side of the face, so that side does not smile or close its eye properly
• 🌀 Vertigo, ringing or hearing loss on the same side
• ⏱️ Antiviral treatment started within 72 hours gives the best chance of full facial recovery, usually with a steroid. Started late, recovery is less complete

A painful ear with blisters, or with any facial weakness, is a same-day problem. Valtrex (Valacyclovir) is among the antivirals used, and shingles and how it is treated covers the wider picture.

💊 Does it need an antibiotic?

Collected in one place, because this is the decision that most often goes wrong.

❌ What to stop doing

• 🚫 Cotton buds. They push wax inward, scratch the canal skin and strip the protective layer that keeps infection out. The canal clears itself outward — wax migrates out on its own, and nothing needs inserting to help it
• 🕯️ Ear candling. No drainage occurs, the residue in the cone is candle wax rather than ear wax, and it has caused burns and canal blockage
• 🚬 Olive oil or peroxide into a painful ear of unknown cause. Fine for softening wax in a healthy ear, unhelpful or harmful if the drum is perforated
• 🎧 Earbuds for hours in heat. They trap moisture and warmth in a closed tube, which is the exact condition canal infection needs. Give the ears dry air between uses
• 🏊 Swimming through an active canal infection, which is the commonest reason treatment fails
• 💊 A third course of the same drops without the ear being looked at again
• 🛏️ Sleeping on the painful side, which makes it worse overnight

For pain itself, paracetamol and ibuprofen work well and work better together than either alone, which covers most people while the cause is sorted out. A warm compress held against the ear helps, and takes nothing away from treatment.

📞 When to seek help

Book an appointment if:

• One-sided ear pain or blockage lasting more than a few weeks with a normal-looking ear — the item from the red flag section, and the reason to not simply wait it out
• Canal infection that has not improved after a week of drops, which usually means the canal needs clearing or the organism is fungal
• You have diabetes and severe ear pain, particularly deep pain at night — this is assessed differently
• Discharge from the ear, which may mean a perforation and changes which drops are safe
• Hearing has not returned once the pain settled
• Repeated episodes of canal infection, since the trigger is usually identifiable and removable
• Earache that is clearly worse on chewing, with jaw clicking — a dental or jaw assessment rather than an ear one
• A blocked ear every time you fly, which is manageable with preparation
• You wear hearing aids and the canal is sore, since fit and cleaning are usually the cause
• Ringing in one ear that persists, particularly with hearing loss on that side
• You have been given antibiotics twice for the same ear with no improvement, which means the diagnosis should be revisited rather than the prescription repeated

❓ Frequently asked questions

📑 Sources and editorial

• Clinical guidance on the assessment and management of otitis externa in adults, including topical antibiotic and corticosteroid treatment, aural toilet, water precautions and indications for systemic therapy
• Evidence on the limited penetration of oral antibiotics into ear canal skin and the resulting preference for topical treatment in uncomplicated otitis externa
• Guidance on otomycosis, including its association with prior topical antibiotic use, presenting features and antifungal management
• Guidance on the ototoxic potential of aminoglycoside-containing ear preparations and their avoidance in suspected tympanic membrane perforation
• Clinical guidance on necrotising otitis externa, including association with diabetes mellitus and immunosuppression, presenting features, facial nerve involvement, imaging, and prolonged systemic antipseudomonal therapy
• Guidance on antibiotic selection for acute otitis media, including amoxicillin as first-line therapy, amoxicillin with clavulanate for recent antibiotic exposure or treatment failure, and cephalosporin or macrolide alternatives in penicillin allergy
• Literature on the anatomical differences in Eustachian tube orientation between children and adults and the resulting difference in incidence of acute otitis media
• Literature on referred otalgia, including temporomandibular joint dysfunction, dental sources, oropharyngeal and tonsillar causes via the glossopharyngeal nerve, cervical spine causes, and neuralgias
• Referral guidance on persistent unilateral otalgia or unilateral middle ear effusion in adults with a normal otoscopic examination, and the requirement for nasopharyngeal assessment
• Head and neck cancer referral criteria, including unilateral otalgia, unilateral hearing loss, neck lump, persistent hoarseness, dysphagia, unexplained weight loss and unilateral epistaxis
• Guidance on Ramsay Hunt syndrome, including pain preceding vesicles, facial nerve palsy, vestibulocochlear involvement, and the effect of antiviral initiation within 72 hours on facial nerve recovery
• Evidence on combined paracetamol and ibuprofen for acute pain compared with either agent alone
• Position statements on ear candling, including absence of demonstrable benefit and documented harms, and guidance against cotton bud use for ear cleaning
• Guidance on Eustachian tube dysfunction, barotrauma and impacted cerumen, and the absence of a role for antibiotics in these conditions
• Related reading: ear infection in children and which antibiotic is used, chronic ear infection, glue ear and grommets, tonsillitis, allergic rhinitis, bacterial sinusitis, shingles
• Related products: Amoxil (Amoxicillin), Augmentin (Amoxicillin + Clavulanate), Cipro (Ciprofloxacin), Ceftin (Cefuroxime), Valtrex (Valacyclovir), antibiotics category
• RXshop Editorial Team — reviewed by Emily Chen, MD, MPH — Internal Medicine Specialist