Remembering/rediscovering the classics: Blocking the nerve of Arnold in the management of myringotomy and tube pain
Santhanam Suresh MD and Myron Yaster MD
Myringotomy and tympanostomy (PE) tube placement is amongst the most common surgical procedures performed in children. Because the surgery is performed mostly in otherwise healthy, young (< 5 years old) children, and usually takes less than 10-15 minutes to perform, it is often done under mask general anesthesia and no IV. Analgesia is often provided with perioperative enteral (PO or PR) acetaminophen and/or ibuprofen (or in Europe diclofenac). Additionally, or alternatively, intramuscular ketorolac plus/minus fentanyl is administered in the OR while the child is anesthetized.[1] In 2008, my good friends Suresh and Charlie Cote, together with their colleagues at Lurie Children’s hospital, published an article in the journal Pediatric Anesthesia describing the blockade of the auricular branch of the vagus (Nerve of Arnold) which supplies the external auditory meatus as well as the inferior portion of the tympanic membrane as a method of providing analgesia for PE tube placement.[2] For reasons that were never clear to me, this block never gained widespread (or really any) traction. Indeed, have you ever heard of this block? Or used it in your practice? I suspect not. In today’s PAAD, I asked Suresh, one of our specialty’s true pioneers and champions of pediatric regional anesthesia and the senior author of today’s paper to assist me in remembering, or perhaps better said, rediscovering this classic paper. Perhaps, in this age of minimizing opioid use, we can resurrect/rediscover this block? Myron Yaster MD
I think the impetus for looking for an alternative to IM ketorolac was to prevent any bleeding and displacement of the PE tube. Perusing through my old edition of Gray’s Anatomy, I thought of this block as an alternative to provide analgesia for this most common pediatric surgical procedure. In fact, one of the big roadblocks was to get the IRB to approve the study. They initially turned it down because of an absence of any published data to show that the block would work. Charlie encouraged me to directly present to the IRB committee in person to explain what we were going to embark upon, and they finally agreed. On the other hand, I think the ease of providing an IM shot of Ketorolac plus/minus fentanyl is the major driver for underutilization of this block. Santhanam Suresh, MD
Original article
Voronov P, Tobin MJ, Billings K, Coté CJ, Iyer A, Suresh S. Postoperative pain relief in infants undergoing myringotomy and tube placement: comparison of a novel regional anesthetic block to intranasal fentanyl--a pilot analysis. Paediatr Anaesth. 2008 Dec;18(12):1196-201. doi: 10.1111/j.1460-9592.2008.02789.x. PMID: 19076574.
The auricular branch of the vagus (Nerve of Arnold) supplies the external auditory meatus as well as the inferior portion of the tympanic membrane. Because PE tubes are placed in the inferior portion of the tympanic membrane, Voronov et al. postulated that peripheral blockade of the nerve of Arnold would provide “ample pain relief in patients undergoing PE tube placement.” I (SS) was fortunate to be working with Dr. Charlie Cote, who at the time was the director of clinical research in the Division of Pediatric Anesthesia at Children’s Memorial Hospital in Chicago (now Lurie Children’s Hospital) who assisted me and the team I assembled to design and perform a randomized, prospective, double blind, controlled trial of the nerve of Arnold block in children who underwent PE tube placement.
Methods: Children 6 months to 6 years were randomized to two groups using a computerized table of random numbers. One group (Group F), received intranasal fentanyl, 2 mcg/kg,[3] followed by a nerve of Arnold block with 0.2 mL of preservative-free normal saline bilaterally; the second group (Group B), received intranasal, preservative-free saline, followed by a nerve of Arnold block with 0.2 ml. of 0.25% bupivacaine with 1 : 200 000 epinephrine bilaterally.
A power analysis demonstrated that for postoperative analgesia, reducing pain rescue from 40% (opioid) to 20% (proposed for nerve block) would require 80 patients per group with an alpha of 0.05 and a power of 0.8. A power analysis with an alpha of 0.05 and a power of 0.8 for reduction in vomiting required 100 patients in each group, assuming that vomiting in the nerve block group would be similar to rectal or oral acetaminophen.”[2]
What did Voronov et al. find? “There was no difference in the pain scores between groups (P = 0.53); there was no difference in the amount of rescue medications between groups (P = 0.86); there was no difference in the incidence of nausea and vomiting between groups (P = 0.34); there was no difference in the time to discharge between groups (P = 0.5).” The authors concluded that blocking the nerve of Arnold provided analgesia that was equal to that provided by nasal fentanyl (non-inferior).
In 2025, the most common analgesic technique for PE tubes is IM ketorolac plus minus fentanyl. We think a non-inferiority randomized controlled study comparing the nerve of Arnold block to this IM regimen is long overdue. We are hoping that someone reading today’s PAAD will do this. In the meantime, why not try this block? It is simple and takes only seconds to perform. Send your thoughts and comments, and any experience you have with the block to Myron, who will post in a Friday reader’s response.
References
1. Stricker PA, Muhly WT, Jantzen EC, Li Y, Jawad AF, Long AS, Polansky M, Cook-Sather SD: Intramuscular Fentanyl and Ketorolac Associated with Superior Pain Control After Pediatric Bilateral Myringotomy and Tube Placement Surgery: A Retrospective Cohort Study. Anesthesia and Analgesia 2017, 124(1):245–253.
2. Voronov P, Tobin MJ, Billings K, Coté CJ, Iyer A, Suresh S: Postoperative pain relief in infants undergoing myringotomy and tube placement: comparison of a novel regional anesthetic block to intranasal fentanyl--a pilot analysis. Paediatric anaesthesia 2008, 18(12):1196–1201.
3. Galinkin JL, Fazi LM, Cuy RM, Chiavacci RM, Kurth CD, Shah UK, Jacobs IN, Watcha MF: Use of intranasal fentanyl in children undergoing myringotomy and tube placement during halothane and sevoflurane anesthesia. Anesthesiology 2000, 93(6):1378–1383.