What's the next step for an adult or child with pressure in both ears and diminished hearing, who has taken Sudafed (Pseudoephedrine) for a month with no improvement?

Immediate Referral to ENT for Formal Audiometry and Otoscopic Examination

After 1 month of Sudafed without improvement, this patient requires urgent ENT evaluation with formal audiometry to distinguish between conductive and sensorineural hearing loss—the management pathways are completely different and time-sensitive treatment windows may be closing.

Why Sudafed Alone is Insufficient

• Pseudoephedrine (Sudafed) is FDA-approved for short-term symptomatic relief only, with explicit warnings to stop use if symptoms persist beyond 7 days 1
• The American Academy of Otolaryngology-Head and Neck Surgery states that oral decongestants provide only very short-term improvements and are not recommended for long-term management of Eustachian tube dysfunction 2
• One month of persistent bilateral ear pressure with hearing loss is not simple Eustachian tube dysfunction—this requires diagnostic workup to rule out serious pathology 3, 4

Critical First Step: Distinguish Conductive from Sensorineural Hearing Loss

The management diverges completely based on hearing loss type 3, 4:

If Conductive Hearing Loss (CHL):

• Otoscopic examination will likely show abnormalities: middle ear effusion, tympanic membrane retraction, cerumen impaction, or other structural pathology 3
• Common causes include middle ear effusion, cholesteatoma, ossicular problems, or chronic Eustachian tube dysfunction 4
• Prognosis is generally good with appropriate medical or surgical intervention 4
• Treatment options include observation with nasal balloon auto-inflation (NNT=9 for clearing effusion), or tympanostomy tubes if symptoms persist >3 months 2

If Sensorineural Hearing Loss (SNHL):

• Otoscopic examination will typically be normal 3
• This represents a potential otologic emergency, especially if sudden onset 3
• Time-sensitive treatment window: corticosteroids are most effective within 2 weeks of symptom onset 3
• Approximately one-third to two-thirds of sudden sensorineural hearing loss patients may recover spontaneously within 2 weeks, but those without improvement in the first 2 weeks are unlikely to show significant recovery 3

Immediate Actions Required

1. Obtain Formal Audiometry

• Pure tone audiometry with air and bone conduction thresholds is essential to quantify hearing loss and determine type 3, 4, 5
• Speech audiometry and tympanometry should be included 4
• Patients cannot accurately distinguish subjective hearing loss as conductive versus sensorineural—objective testing is mandatory 3

2. Complete Otoscopic Examination

• Pneumatic otoscopy to assess tympanic membrane mobility and middle ear status 3
• Remove any cerumen impaction prior to establishing diagnosis 3
• Weber and Rinne tuning fork tests can provide bedside differentiation but must be confirmed with audiometry 3

3. Assess for Red Flags

• Bilateral sudden hearing loss requires immediate evaluation for systemic causes 3
• Asymmetric sensorineural hearing loss may indicate retrocochlear pathology (vestibular schwannoma, meningioma) requiring MRI 4, 5
• Associated vertigo, severe tinnitus, or focal neurologic findings warrant urgent workup 3

Treatment Pathways Based on Diagnosis

If Sudden Sensorineural Hearing Loss (SSNHL):

• Corticosteroids may be offered as initial therapy if within 2 weeks of symptom onset 3
• Oral prednisolone (60 mg daily for 5 days with taper) or dexamethasone (40 mg daily for 5 days) are standard regimens 6, 7, 8
• Intratympanic corticosteroids can be offered as salvage therapy if oral steroids fail or are contraindicated 3, 9
• MRI of brain and internal auditory canals should be obtained to rule out vestibular schwannoma 3, 5
• Follow-up audiometry within 6 months is recommended to assess treatment outcome 3, 5

If Chronic Eustachian Tube Dysfunction with Effusion:

• Continue conservative management with nasal balloon auto-inflation 2
• Avoid prolonged topical nasal decongestants (maximum 3 days) to prevent rhinitis medicamentosa 2
• Intranasal corticosteroids are NOT recommended for Eustachian tube dysfunction 2
• If symptoms persist >3 months, tympanostomy tube insertion provides high-level evidence of benefit with 6-12 dB hearing improvement 2

Critical Pitfalls to Avoid

• Never assume bilateral ear pressure with hearing loss is simple congestion after 1 month—this requires formal evaluation 3, 4
• Do not continue oral decongestants beyond 7 days per FDA labeling 1
• Do not delay audiometry—if this is SSNHL, the optimal treatment window (within 2 weeks) may have already passed 3
• Do not miss bilateral SSNHL, which requires evaluation for systemic causes including autoimmune disease 3, 6
• Recognize that mixed hearing loss (both conductive and sensorineural components) requires specialist management 4