Why are we struggling to manage ear pain?
Reviewed by Thomas William Binnersley

Ear pain can be consumptive. It gnaws like toothache, splits like a headache and can throw off one’s equilibrium. Despite this, we often treat the cause without treating the symptoms. Stoliar and colleagues compared how physicians assess and treat pain in three otological conditions (acute otitis externa, acute otitis media, and bullous myringitis) with conservatively-managed urolithiasis (kidney stones) in an emergency department setting. Why kidney stones? Because they cause the ‘worst pain imaginable’? Let us not debate this received wisdom; rather, it provides a suitable benchmark as their management relies heavily on symptom control. The authors examined three domains: pain documentation, inpatient pain management, and discharge pain management planning. They found four out of five patients with stones were offered inpatient analgesia compared to 13% of ear patients. A similar proportion of stones patients were offered prescription analgesia on discharge, compared with 7–17% of ear patients. Among those discharged with pain medication, stones patients were more often prescribed multimodal analgesia regimens, while ear patients more commonly received opioid-based monotherapies. But why is this the case? Is it because stones are more painful than ear infections? Perhaps. This study reports a higher median VAS score for stones (8.0) than for ear conditions (5.0; p<). However I doubt the reliability of such scoring systems when extrapolated from retrospective documentary datasets. We also lack data on over-the-counter analgesia, or on analgesia prescribed by primary care providers who are more likely to have assessed ear patients first. It is also possible that emergency physicians provide more effective front-of-house pain management than ENT surgeons. It is clear that more structured protocols exist for the management of stone pain, while ear pain management is more physician dependent, increasing the likelihood of mismanaged or depersonalised pain control in emergency settings. Emergency physicians should remember to utilise NSAIDs (safely, of course), consider multimodal analgesia and ascend the WHO pain ladder to reach new heights in ear pain management.

Evaluation of Pain Management in Acute Otologic Conditions by Otolaryngologists: A Case-Control Study.
Stoliar K, Mustafa GA, Saied SE et al.
ANN OTOLOGY RHINOL LARYNGOL
2026;34894251406466.