Update Course Rewind 2025: Nerve Monitoring in Pediatric Thyroid Surgery
With Dr. Ben Hamm · hosted by Dr. Jill Knepprath
Part of
Thyroid Nodules 3 items
Chapter 1 of 4 · Case-Based Learning
Case presentation
Case presentation and initial management of pediatric thyroid nodule
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What the experts said
For Bethesda 3 thyroid nodules in pediatrics, lobectomy is recommended rather than molecular testing or repeat FNA because there is a higher rate of malignancy in pediatric populations compared to adults
For a nodule with intermediate risk of cancer (approximately 30% malignancy rate), hemithyroidectomy rather than total thyroidectomy is recommended
The 2015 pediatric guidelines recommend thyroid surgery be done by a high volume thyroid surgeon
One recent study published the rate of recurrent laryngeal nerve injury decreasing from 8% to 1.5% with nerve monitoring
Studies in adults have shown that nerve monitoring helps identify the nerve more, but maybe doesn't change injury rates
There are no studies in pediatrics showing significant decrease in injury rates with nerve monitoring, but there are several that show absolute decrease
The evidence on whether intraoperative nerve monitoring prevents recurrent laryngeal nerve injury is mixed and open for meta-analysis
Recurrent laryngeal nerve injury rate in children is 9% versus about 6% in adults, possibly because it's a smaller nerve that may be harder to identify
If injury is detected on one side with nerve monitoring, the surgeon may want to wait and see if it's a transient injury that can recover later
Expense is one consideration as a downside to nerve monitoring
Some have questioned why use nerve monitoring if it doesn't change injury rates or outcomes
Recent endotracheal tube electrode publications show nerve monitoring has been tried in patients down to age 0
Nerve monitoring is most beneficial when doing a total thyroidectomy where the contralateral cord is at risk, to help decrease the risk of tracheotomy with bilateral paralysis
If a child is too small for the endotracheal tube electrodes, the electrodes come separate and can be placed directly into the vocalis muscle via direct laryngoscopy for monitoring
A recent paper suggested that if you adjust the size criteria in TIRRADS, it actually performs better than the 2015 pediatric guidelines
A larger institutional study through the Pediatric Surgical Oncology Research Collaborative using the modified PES-TIRRADS recommends biopsy for every TIRRADS 3 nodule over 1 cm or TIRRADS 4-5 over 0.5 cm
Thyroid nodules are more common in adults than in children, so there are not many centers with pediatric surgeons who have high volume of these cases
If biopsy comes back as cancer, completing thyroidectomy is the next recommended step
In thyroid surgery, intraoperative nerve monitoring is a technique to localize the recurrent laryngeal nerves which control the vocal cords using an electric probe that stimulates the nerve while EMG electrodes monitor vocal cord movement
In a recent survey, 80% of pediatric thyroid surgeons use nerve monitoring
Nerve monitoring detects injury early, allowing surgeons to stage the operation and avoid bilateral injury, paralysis, and subsequent tracheotomy
Nerve monitoring devices were often too big for pediatric patients in the past
Nerve monitoring can be considered in all pediatric thyroid surgeries because adhesive electrodes can be applied to even a 3.0 endotracheal tube
Radiologists say that TIRRADS is not really reliable for pediatrics since it was originally developed for adults
When criteria was based on the size of the thyroid relative to the size of the patient, no malignancies were missed
Dr. Aldrin's 2025 study showed that the PES-TIRRADS eliminated unnecessary biopsies while not missing a single thyroid malignancy compared to adult and 2015 pediatric guidelines