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Update Course Rewind 2025: Nerve Monitoring in Pediatric Thyroid Surgery
With Dr. Ben Hamm · hosted by Dr. Jill Knepprath
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
For pediatric patients with Bethesda 3 thyroid nodules, 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%), thyroidectomy is not recommended because the patient probably only needs a hemithyroidectomy
The 2015 pediatric guidelines recommend thyroid surgery being 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 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
Recurrent laryngeal nerve injuries may happen more in children because it's a smaller nerve that may be harder to identify, with a rate of 9% in children versus about 6% in adults
If injury is detected on one side with nerve monitoring, the surgeon may want to wait and see if it's just a transient thing that can recover later
Expense is one consideration as a downside to nerve monitoring, and some have questioned its use if it doesn't change injury rates or outcomes
Recent endotracheal tube electrode publications show nerve monitoring has been tried in children down to age 0
Nerve monitoring is most beneficial when doing a total thyroidectomy where the contralateral cord is paralyzed, to help decrease the risk of tracheotomy with bilateral paralysis
If a child is too small for the 5.0 or 3.0 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 or 5 over 0.5 cm
TIRRADS (Thyroid Imaging Reporting and Data System) is a scoring system developed for adults to stratify the risk of thyroid nodules based on ultrasound findings
Thyroid nodules are more common in adults than in children, so there are not many centers that have a pediatric surgeon with high volume of these cases
In thyroid surgery, intraoperative nerve monitoring is a technique to localize the recurrent laryngeal nerves which control the vocal cords using an electric probe to stimulate the nerve and EMG electrodes to 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
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