What is the diagnosis and treatment for cough, congestion, and ear pressure?

Diagnosis and Treatment of Cough, Congestion, and Ear Pressure

Based on your symptom constellation of cough, congestion, and ear pressure, the most likely diagnosis is Upper Airway Cough Syndrome (UACS), and you should start treatment immediately with a first-generation antihistamine/decongestant combination such as brompheniramine with sustained-release pseudoephedrine. 1

Initial Diagnostic Approach

The key clinical features to assess include:

• Duration of symptoms: Acute (<3 weeks), subacute (3-8 weeks), or chronic (>8 weeks) 2, 3
• Medication history: Specifically whether you're taking an ACE inhibitor, which can cause chronic cough 1, 2
• Smoking status: Active smoking exacerbates cough and must be addressed 1, 3
• Red flag symptoms: Fever >38.5°C, respiratory distress (increased respiratory rate, intercostal retractions, cyanosis), hemoptysis, or weight loss 2, 3

Your triad of cough, congestion, and ear pressure strongly suggests UACS (formerly called postnasal drip syndrome), which is the most common cause of both acute and chronic cough. 1 The ear pressure indicates Eustachian tube involvement from upper airway inflammation, further supporting this diagnosis. 1

Immediate Treatment Strategy

First-Line Therapy

Start a first-generation antihistamine/decongestant combination immediately: 1, 2

• Brompheniramine with sustained-release pseudoephedrine is specifically recommended 1
• Do NOT use newer non-sedating antihistamines (like loratadine or cetirizine) as they are ineffective for cough 1

Add naproxen 220-440mg twice daily to help decrease cough and inflammation 1

Expected Response Timeline

• Continue treatment for 1-2 weeks to assess response 1
• Improvement or resolution of cough confirms UACS as the diagnosis 1
• The ear pressure should resolve as upper airway inflammation decreases 1

If Symptoms Persist Beyond 1-2 Weeks

Sequential Evaluation and Treatment

If no improvement after initial therapy, proceed systematically: 1

1. Obtain sinus imaging (CT sinuses) to evaluate for chronic sinusitis, which can be clinically silent with minimal findings on examination 1

2. Consider asthma as the next most likely cause: 1, 2

   • Asthma can present with cough alone without wheezing or dyspnea ("cough variant asthma") 1
   • Perform spirometry; if normal, consider bronchoprovocation challenge 1
   • If testing unavailable, start empiric trial of inhaled corticosteroids plus bronchodilators 1, 2, 3

3. Evaluate for gastroesophageal reflux disease (GERD): 1

   • GERD can cause cough without typical heartburn symptoms ("silent GERD") 1
   • Start empiric proton pump inhibitor therapy if UACS and asthma treatments fail 1

Critical Pitfalls to Avoid

Multiple causes often coexist—treat sequentially and additively, not exclusively: 1, 2

• Up to 62% of chronic cough patients have more than one contributing factor 1
• Don't stop UACS treatment when adding asthma therapy; layer treatments 1

Don't rely on cough characteristics for diagnosis: 1

• The timing, quality, or productivity of cough does not reliably distinguish between causes 1

Avoid antibiotics unless bacterial sinusitis is confirmed: 1

• Don't diagnose bacterial sinusitis during the first week of symptoms 1
• Most cases are viral and resolve with symptomatic treatment 2

When to Obtain Chest Radiography

Order a chest X-ray if: 2, 3

• Fever, tachypnea, or abnormal lung examination suggesting pneumonia 2
• Cough persists beyond 8 weeks (chronic cough) 1, 4
• Risk factors for lung cancer (smoking history, age >40, hemoptysis) 1

Special Considerations

If you're taking an ACE inhibitor: Stop it immediately and switch to an alternative antihypertensive, as ACE inhibitors cause chronic cough in 5-35% of patients 1, 2, 3

If symptoms worsen or you develop high fever (>38.5°C), respiratory distress, or severe symptoms: Seek immediate evaluation for possible pneumonia or other serious infection 2