What is the appropriate management for a 78‑year‑old woman with recurrent upper‑respiratory complaints who has been repeatedly treated with systemic steroids (methylprednisolone 40 mg, dexamethasone 4 mg) and antibiotics for presumed eustachian‑tube dysfunction without objective middle‑ear testing such as tympanometry?

Inappropriate Systemic Steroid Use for Eustachian Tube Dysfunction

This patient is receiving inappropriate and potentially harmful treatment: systemic corticosteroids (methylprednisolone 40 mg, dexamethasone 4 mg) have no established role in treating eustachian tube dysfunction (ETD) and should be discontinued immediately. 1

The Core Problem: Lack of Objective Diagnosis

• Tympanometry must be performed before any further treatment to objectively confirm middle ear pathology, as clinical examination alone is insufficient to distinguish ETD from other conditions 2
• Without tympanometry or pneumatic otoscopy, the diagnosis of ETD remains presumptive and may be incorrect 2
• A normal type A tympanometry tracing (peaked curve with normal pressure) indicates an intact tympanic membrane and normal middle ear pressure, which would argue against significant ETD 2

Evidence Against Systemic Steroids for ETD

The evidence is clear that oral steroids should not be used for ETD or otitis media with effusion:

• A systematic review of interventions for adult ETD found that nasal steroids showed no improvement in symptoms or middle ear function for patients with middle ear effusion and/or negative middle ear pressure 3
• The National Quality Foundation endorses avoiding oral steroids for otitis media with effusion as a performance measure 1
• National data shows only 3.2% of ETD/OME visits result in oral steroid prescriptions (2.3% in children, 7.0% in adults), indicating this is not standard practice 1
• No controlled studies support the use of systemic steroids for ETD 3

Harms of Repeated Systemic Steroid Exposure

At 78 years old, this patient faces significant risks from repeated steroid courses:

• Common adverse effects include hyperglycemia, hypertension, weight gain, insomnia, osteoporosis, cataracts, glaucoma, increased infection risk, and mood disturbances 2
• Osteonecrosis and fractures occur more commonly in elderly patients with preexisting bone or joint problems 2
• These risks accumulate with repeated courses, which this patient is receiving multiple times per year 2

Appropriate Management Algorithm

Step 1: Establish Objective Diagnosis

• Perform tympanometry immediately to document middle ear status 2
• Conduct pneumatic otoscopy to assess tympanic membrane mobility 2
• Consider the 7-item Eustachian Tube Dysfunction Questionnaire (ETDQ-7) to quantify symptom severity 4

Step 2: Differentiate True ETD from Other Conditions

• Rule out acute otitis media (which would show bulging tympanic membrane with middle ear effusion) 5
• Distinguish from otitis media with effusion (OME), which shows middle ear effusion without acute inflammation 2
• Consider that isolated tympanic membrane erythema without abnormal landmarks does not indicate bacterial infection and should not be treated with antibiotics 5

Step 3: Evidence-Based Treatment for Confirmed ETD

If ETD is confirmed:

• Intranasal corticosteroids (e.g., budesonide nasal spray, 2 sprays twice daily) may provide benefit, though evidence is limited 4, 6
• Nasal decongestants for very short-term use only (not chronic management) 3
• Autoinflation devices or pressure equalization techniques showed short-term improvements in limited studies 3

For refractory cases:

• Referral to otolaryngology for consideration of balloon eustachian tuboplasty, which has shown promise in case series 6, 3
• Myringotomy with or without tube placement for persistent middle ear effusion 3

Step 4: Stop Inappropriate Treatments

• Discontinue systemic corticosteroids immediately 1
• Discontinue antibiotics unless acute bacterial infection is documented 5
• Repeated courses of antibiotics for presumed ETD without bacterial confirmation contribute to antimicrobial resistance 5

Critical Pitfalls to Avoid

• Do not prescribe systemic steroids for ETD or OME – this is explicitly discouraged as a quality measure 1
• Do not treat isolated tympanic membrane erythema with antibiotics – this commonly occurs with viral upper respiratory infections without bacterial middle ear infection 5
• Do not continue empiric treatment without objective testing – tympanometry is simple, non-invasive, and essential for proper diagnosis 2
• Do not assume recurrent visits indicate treatment failure – they may indicate misdiagnosis or inappropriate treatment selection 1

Special Considerations for Elderly Patients

• Adults are more likely to receive inappropriate steroid prescriptions than children (7.0% vs 2.3%), suggesting a pattern of overtreatment 1
• Patients seen by otolaryngologists are less likely to receive inappropriate steroids, supporting the value of specialist referral 1
• The cumulative burden of repeated steroid and antibiotic courses in a 78-year-old patient substantially increases risk without evidence of benefit 2