How to manage a case of perichondritis pinna, possibly due to herpes, with severe pain unresponsive to paracetamol (acetaminophen) and tramadol?

Management of Severe Pain in Perichondritis Pinna

For severe pain in perichondritis unresponsive to paracetamol and tramadol, immediately escalate to strong opioids (morphine, oxycodone, or hydromorphone) administered parenterally, combined with NSAIDs if not contraindicated, while ensuring appropriate anti-pseudomonal antibiotic coverage and considering surgical drainage. 1, 2

Immediate Pain Management Algorithm

Step 1: Escalate to Strong Opioids

• Administer subcutaneous or intravenous morphine for rapid relief of acute severe pain 1, 2
• Alternative strong opioids include oxycodone injection or hydromorphone (particularly if the patient has renal impairment) 1, 2
• The combination of paracetamol and tramadol has failed, indicating you are dealing with severe pain requiring WHO Step III analgesics 3
• Tramadol has a ceiling effect and increasing doses will not provide additional benefit 3

Step 2: Add NSAIDs if Not Contraindicated

• Administer NSAIDs during the acute inflammatory phase, as they significantly reduce pain compared to placebo in inflammatory conditions 1
• Ibuprofen 400mg three times daily (1.2g/day) is the preferred NSAID due to favorable safety profile 4
• Avoid NSAIDs if the patient has renal impairment, heart failure, or gastrointestinal bleeding history 4
• The inflammatory component of perichondritis responds well to anti-inflammatory medications 1

Step 3: Consider Adjuvant Analgesics for Neuropathic Component

• If pain has neuropathic characteristics (burning, shooting, hypersensitivity), add gabapentin or pregabalin 1, 2
• Perichondritis can involve nerve irritation given the proximity of sensory nerves to the inflamed perichondrium 1

Critical Treatment Considerations

Address the Underlying Infection

• Pseudomonas aeruginosa is the predominant pathogen in 33-69% of perichondritis cases and is associated with more severe clinical presentation 5, 6, 7
• Anti-pseudomonal antibiotics are essential and should have been started immediately 5, 6, 7
• Most patients are not prescribed appropriate anti-pseudomonal coverage initially, leading to persistent infection and poor outcomes 5

Surgical Intervention May Be Necessary

• 80% of pinna abscess cases require surgical drainage, and delayed intervention is associated with residual deformity 6
• If there is abscess formation or purulent collection, surgical drainage is indicated 6, 7
• Longer duration before presentation correlates with worse cosmetic outcomes 6

If Herpes Zoster is Suspected

• Initiate antiviral therapy within 72 hours of rash onset to reduce severity and duration 8
• Antivirals do not prevent postherpetic neuralgia but are effective for acute herpes zoster 8
• The pain management strategy remains the same regardless of viral etiology 8

Specific Dosing for Severe Pain

Morphine Administration

• Start with immediate-release morphine 5-10mg subcutaneously or intravenously every 4 hours 2
• Provide rescue doses (same amount) available up to hourly for breakthrough pain 2
• Titrate based on pain response and side effects 2

Mandatory Adjunctive Measures

• Prescribe laxatives routinely for prevention of opioid-induced constipation 1, 2
• Prescribe antiemetics (metoclopramide or antidopaminergic drugs) for opioid-related nausea 2

Common Pitfalls to Avoid

Do Not Continue Inadequate Analgesia

• Pain is easier to prevent than treat, so early aggressive treatment at appropriate doses is essential 1
• Fixed-interval dosing is more effective than "as needed" dosing when frequent administration is required 1, 2

Do Not Delay Surgical Consultation

• Average time to ENT consultation in perichondritis cases is nearly 10 days, which is associated with worse outcomes 6
• Residual deformity occurs in 28.6% of cases, all of which required surgical drainage 6

Assess for Renal Function Before Opioid Selection

• If renal impairment is present (eGFR <30), fentanyl or buprenorphine are safer than morphine 2
• All opioids require dose reduction in renal impairment 2

Reassessment Strategy

• Use validated pain scales (visual analog scale, numerical rating scale) to objectively track response 1, 2
• Reassess pain intensity within 1-2 hours of parenteral opioid administration 1
• If pain remains uncontrolled despite strong opioids and NSAIDs, consider nerve block with local anesthetic 1