Dr. Jessica Grayson (left) and Dr. James Johnston perform an endoscopic procedure on a patient at Children’s of Alabama.
A growing number of children with complex skull base conditions can now be treated with minimally invasive surgery at Children’s of Alabama thanks to a collaboration between pediatric neurosurgeon James M. Johnston, M.D. and otolaryngologist Jessica Grayson, M.D. Together, they lead an integrated pediatric skull base surgery program that offers endoscopic procedures for conditions such as skull base tumors, traumatic injuries, complex pituitary lesions, and congenital abnormalities such as encephaloceles—in which brain tissue protrudes through an opening in the skull.
“Endoscopic approaches have been part of pediatric neurosurgery here for years for things like hydrocephalus or intraventricular tumors,” said Johnston, director of the Division of Pediatric Neurosurgery at Children’s and the University of Alabama at Birmingham (UAB). “What’s new and exciting is how we’ve expanded endonasal skull base surgery through this collaboration.”
The procedure involves threading a tiny camera and instruments through the patient’s nasal passages to reach the brain. “That means smaller incisions, less blood loss and a much shorter recovery time,” said Grayson—one of the few clinicians in the country who is fellowship trained in rhinology and skull base surgery for both adults and children, with extensive expertise in endoscopic endonasal surgery.
After tumor removal, Grayson works to patch any small holes created between the brain and the nose. This is one of the most critical aspects after the removal—if the small holes aren’t properly sealed, cerebral spinal fluid could leak out into the nose, leading to a high risk of infection. Grayson typically uses a nasoseptal flap to close any openings. She peels a small piece of the mucosa covering the nasal septum while maintaining its blood supply, then flips it over to cover any holes created during surgery.
The program is multidisciplinary, involving ENT, neurosurgery and occasionally plastic surgery. The team-based model also allows for comprehensive case review and planning. “We often consult with our adult colleagues at UAB when a case is really complex,” Johnston said. “It’s like having a built-in tumor board.”
Offering this type of approach for children is another way the program is unique—this method typically has been reserved for adults. And “the technical aspects are different from adult cases,” given their smaller anatomy and less-developed sinuses, Johnston noted. “But with collaboration, it’s absolutely feasible. We’ve even done this in infants as young as a few months old.”
The first collaboration—a case of congenital encephalocele in which the protruding tissue was initially mistaken for adenoid tissue—highlighted the potential of combining expertise. “That was the moment we realized we could safely and effectively treat these cases together using a minimally invasive endoscopic approach,” Grayson said.
Nationally, this type of program is rare. “In many places, kids are sent to adult hospitals for these procedures,” Grayson said. “Here, they can stay in a pediatric environment with pediatric anesthesiologists, nurses and postoperative care, which is crucial for safety and comfort.”
Last year, the team did about 40 cases, and the number of referrals is growing as more clinicians become aware of what’s possible. “We’re seeing more cases from outside hospitals,” Johnston said. “And we’re better at recognizing which patients are good candidates.”