Lobectomy for pediatric thyroid nodules is recommended rather than molecular testing or repeat FNA currently because there is a higher rate of malignancy in pediatric populations compared to adults
For children with hypoventilation due to central hypoventilation syndromes, spinal cord injury, ALS, or metabolic disorders, diaphragm pacing is an option that has been able to avoid tracheostomy in some patients or help wean patients off ventilation
In pediatric patients, devices may not have been small enough to monitor nerves, with some publications showing monitoring attempted down to age 4-5, and recent adhesive electrode publications showing use down to age zero
2025 Pediatric Surgery Update Course - Nerve Monitoring and Stimulation in Pediatric Surgery
▶Ep 69 · 0:00
clinicalA 1.1 centimeter thyroid nodule that is TIRADS 4 with Bethesda 3 FNA (atypia of undetermined significance) has approximately 30% risk of cancer↗
▶Ep 69 · 2:00
quoteI think Bethesda 3 you can also repeat the FNA.↗
▶Ep 69 · 3:00
guidelineThe 2015 pediatric thyroid guidelines recommend surgery be performed by a high volume thyroid surgeon, defined as performing 30 thyroid surgeries per year↗
▶Ep 69 · 4:00
guidelineLobectomy for pediatric thyroid nodules is recommended rather than molecular testing or repeat FNA currently because there is a higher rate of malignancy in pediatric populations compared to adults↗
▶Ep 69 · 4:40
clinicalOne recent study showed recurrent laryngeal nerve injury rates decreased from 8% to 1.5% with nerve monitoring↗
▶Ep 69 · 5:10
epidemiologicalIn a recent survey, approximately 80% of pediatric thyroid surgeons use nerve monitoring↗
▶Ep 69 · 5:20
clinicalStudies in adults have shown nerve monitoring may help identify the nerve but may not change injury rates↗
▶Ep 69 · 5:35
epidemiologicalThe rate of recurrent laryngeal nerve injury in children is 9% versus about 6% in adults↗
▶Ep 69 · 6:05
quoteYeah, expense is one consideration and if it doesn't change the injury rates some of said we'll why use it if it doesn't change the outcomes. And others have said well maybe there's just not enough power in the studies to show that.↗
▶Ep 69 · 6:05
opinionExpense is one consideration for not using nerve monitoring, and some argue if it doesn't change injury rates there may be no reason to use it↗
▶Ep 69 · 6:35
clinicalIn pediatric patients, devices may not have been small enough to monitor nerves, with some publications showing monitoring attempted down to age 4-5, and recent adhesive electrode publications showing use down to age zero↗
▶Ep 69 · 7:29
clinicalAdhesive electrodes can now be placed on a 3.0 ET tube, making intraoperative nerve monitoring available for almost all pediatric thyroid surgeries↗
▶Ep 69 · 7:55
opinionNerve monitoring may be most beneficial when doing total thyroidectomy where the contralateral cord is paralyzed, to help decrease risk of tracheostomy with bilateral paralysis↗
▶Ep 69 · 8:15
clinicalIf nerve monitoring shows changes on one side during total thyroidectomy, this might lead the surgeon to delay and do the other side later↗
▶Ep 69 · 8:35
clinicalTIRADS was developed for adults to risk stratify nodules based on ultrasound imaging characteristics, and there has been caution against using it for pediatrics↗
▶Ep 69 · 11:49
clinicalIn a sacral nerve stimulator trial for children with fecal incontinence, the rate of wearing a diaper during the day decreased from 19% to 2%, and at nighttime decreased from 33% to 11%↗
▶Ep 69 · 12:30
clinicalSacral nerve stimulation is not FDA approved in children↗
▶Ep 69 · 12:40
clinicalA Cochrane Review in adults suggests sacral nerve stimulation can help with fecal incontinence↗
▶Ep 69 · 12:50
clinicalA retrospective cohort study with 70 patients showed improvement in involuntary daytime and nighttime bowel movement rates with sacral nerve stimulation↗
▶Ep 69 · 13:10
clinicalSide effects of sacral nerve stimulation include pain and neurological symptoms, and about 40% required re-operation within about three years for dead battery or replacement↗
▶Ep 69 · 13:30
clinicalThe sacral nerve stimulator is placed through the third sacral foramen and sends signals to the sacral nerves, with a trial period of a couple weeks before permanent implantation↗
▶Ep 69 · 14:56
clinicalFor children with hypoventilation due to central hypoventilation syndromes, spinal cord injury, ALS, or metabolic disorders, diaphragm pacing is an option that has been able to avoid tracheostomy in some patients or help wean patients off ventilation↗
▶Ep 69 · 15:44
clinicalDiaphragm pacing can be done via phrenic nerve stimulation or direct diaphragm stimulation with leads implanted in the diaphragm↗
Ben's statements about Thyroid Nodule23 statements
2025 Pediatric Surgery Update Course - Nerve Monitoring and Stimulation in Pediatric Surgery
▶Ep 2 · 0:00
clinicalA 1.1 centimeter thyroid nodule that is TIRADS 4 with Bethesda 3 FNA (atypia of undetermined significance) has approximately 30% risk of cancer↗
▶Ep 2 · 2:00
quoteI think Bethesda 3 you can also repeat the FNA.↗
▶Ep 2 · 3:00
guidelineThe 2015 pediatric thyroid guidelines recommend surgery be performed by a high volume thyroid surgeon, defined as performing 30 thyroid surgeries per year↗
▶Ep 2 · 4:00
guidelineLobectomy for pediatric thyroid nodules is recommended rather than molecular testing or repeat FNA currently because there is a higher rate of malignancy in pediatric populations compared to adults↗
▶Ep 2 · 4:40
clinicalOne recent study showed recurrent laryngeal nerve injury rates decreased from 8% to 1.5% with nerve monitoring↗
▶Ep 2 · 5:10
epidemiologicalIn a recent survey, approximately 80% of pediatric thyroid surgeons use nerve monitoring↗
▶Ep 2 · 5:20
clinicalStudies in adults have shown nerve monitoring may help identify the nerve but may not change injury rates↗
▶Ep 2 · 5:35
epidemiologicalThe rate of recurrent laryngeal nerve injury in children is 9% versus about 6% in adults↗
▶Ep 2 · 6:05
quoteYeah, expense is one consideration and if it doesn't change the injury rates some of said we'll why use it if it doesn't change the outcomes. And others have said well maybe there's just not enough power in the studies to show that.↗
▶Ep 2 · 6:05
opinionExpense is one consideration for not using nerve monitoring, and some argue if it doesn't change injury rates there may be no reason to use it↗
▶Ep 2 · 6:35
clinicalIn pediatric patients, devices may not have been small enough to monitor nerves, with some publications showing monitoring attempted down to age 4-5, and recent adhesive electrode publications showing use down to age zero↗
▶Ep 2 · 7:29
clinicalAdhesive electrodes can now be placed on a 3.0 ET tube, making intraoperative nerve monitoring available for almost all pediatric thyroid surgeries↗
▶Ep 2 · 7:55
opinionNerve monitoring may be most beneficial when doing total thyroidectomy where the contralateral cord is paralyzed, to help decrease risk of tracheostomy with bilateral paralysis↗
▶Ep 2 · 8:15
clinicalIf nerve monitoring shows changes on one side during total thyroidectomy, this might lead the surgeon to delay and do the other side later↗
▶Ep 2 · 8:35
clinicalTIRADS was developed for adults to risk stratify nodules based on ultrasound imaging characteristics, and there has been caution against using it for pediatrics↗
▶Ep 2 · 11:49
clinicalIn a sacral nerve stimulator trial for children with fecal incontinence, the rate of wearing a diaper during the day decreased from 19% to 2%, and at nighttime decreased from 33% to 11%↗
▶Ep 2 · 12:30
clinicalSacral nerve stimulation is not FDA approved in children↗
▶Ep 2 · 12:40
clinicalA Cochrane Review in adults suggests sacral nerve stimulation can help with fecal incontinence↗
▶Ep 2 · 12:50
clinicalA retrospective cohort study with 70 patients showed improvement in involuntary daytime and nighttime bowel movement rates with sacral nerve stimulation↗
▶Ep 2 · 13:10
clinicalSide effects of sacral nerve stimulation include pain and neurological symptoms, and about 40% required re-operation within about three years for dead battery or replacement↗
▶Ep 2 · 13:30
clinicalThe sacral nerve stimulator is placed through the third sacral foramen and sends signals to the sacral nerves, with a trial period of a couple weeks before permanent implantation↗
▶Ep 2 · 14:56
clinicalFor children with hypoventilation due to central hypoventilation syndromes, spinal cord injury, ALS, or metabolic disorders, diaphragm pacing is an option that has been able to avoid tracheostomy in some patients or help wean patients off ventilation↗
▶Ep 2 · 15:44
clinicalDiaphragm pacing can be done via phrenic nerve stimulation or direct diaphragm stimulation with leads implanted in the diaphragm↗
Summaries Ben gave as host
· 2 summaries
Recaps of other experts' statements, not Ben's own clinical position.
Summaries Ben gave as host · Esophageal Atresia1 summary
2025 Pediatric Surgery Update Course - Nerve Monitoring and Stimulation in Pediatric Surgery
▶Ep 69 · 9:00
host summaryBen Ham summarizing the discussion: A recent paper suggested that if you adjust TIRADS size criteria, it performs better than the 2015 pediatric guidelines↗
Summaries Ben gave as host · Thyroid Nodule1 summary
2025 Pediatric Surgery Update Course - Nerve Monitoring and Stimulation in Pediatric Surgery
▶Ep 2 · 9:00
host summaryBen Ham summarizing the discussion: A recent paper suggested that if you adjust TIRADS size criteria, it performs better than the 2015 pediatric guidelines↗
