If the median filter is not effective, then I recommend first assessing the type of noise in the image to make sure if it is really impulse. Try to find a relatively homogeneous texture area in the image and measure the noise therein (by fitting to different noise models).
The papers below apply this simple technique to measuring noise in lung tumor CT images, which can be used on other types of images as well:
- O. S. Al-Kadi, “Assessment of texture measures susceptibility to noise in conventional and contrast enhanced computed tomography lung tumour images,” Computerized Medical Imaging and Graphics, vol. 34(6), pp. 494-503, 2010.
- O. S. Al-Kadi and D. Watson, “Susceptibility of texture measures to noise: an application to lung tumor CT images,” in 8th International Conference on BioInformatics and BioEngineering, Greece, pp. 1-4, 2008.