Case of the Month #23: Ear Pain by Dr Lorraine de Gray
Mr P was managed with a holistic pain management plan.
An explanation was provided with regards to the underlying cause of his problem, which Mr P reported as being very helpful as he had been worried that the tumour had started growing within his ear. He reported that reducing stress and worrying had already made him feel better.
His overall medication was reviewed and it was ascertained that he was not taking any medications of the bisphosphonate family which could have been contributory to the osteonecrosis.
His renal function showed an estimated glomerular filtration rate of 60 mL/min/1.73 m2 and it was therefore deemed to be safe to continue to use morphine for pain relief. The pain appeared to be opioid sensitive and he was tolerating the drug without any significant side effects. It was calculated that he had been taking a total of around 15mg of morphine as Oramorph in a day, and therefore with his consent, he was changed over to MST (Morphine sustained release tablets) 5mg twice daily, with instructions to use Oramorph 2.5mg as additional doses in between only if required.
Consideration was made to adding an oral antineuropathic drug such as a tricyclic or gabapentinoid, but the history of atrial fibrillation and recurrent falls, were considered to make addition of such drugs as too high risk. As he had an area of allodynia on the side of the cheek where the basal cell cancer had been removed, he was prescribed Lidocaine 5% plaster with instructions to cut a small square out of the plaster and apply this for 12 hours per day to the affected area. This appeared to help with removing some of the triggering of pain particularly when out in cold weather or wind.
He also attended for a short course of psychological therapy with one of our Clinical Psychologists who helped survivors of cancer. She provided him with useful tools to help with sleep and containment of stress. Mr P had not only been worried about recurrent cancer, but also about losing his independence and having to go into a nursing home.
When reviewed in the pain clinic twelve weeks later, he appeared much brighter, he was no longer needed any Oramorph and was talking about reducing his MST intake. He had found the Lidocaine 5% plasters helpful, and it was agreed that he would try and drop the MST intake by 5mg in the next month and if this was manageable, he would try and come off the morphine, and continue to use the Lidocaine 5% plasters and Paracetamol for pain relief.