Pushing the Limits for Patients

Doctors collaborate across specialty lines to provide the best care for baby Jude

Jude’s head was marked and ready to go. Purple lines zigzagged from ear to ear, mapping the way for a craniotomy—a neurosurgery where the skull is cut open and lifted to expose the brain. Instead, they served another purpose: inspiring gratitude. 

“The line took a couple weeks to fully wash off, and every time I looked at it, I was reminded of how grateful I am to Stanford,” says Lindsay, Jude’s mom. 

At birth, Lindsay and Jeff Schuil noticed a small bump on Jude’s nose, along with a nearby pore that seemed larger than normal. They asked their pediatrician in Visalia, California, about it. He agreed that it was unusual and suggested monitoring it for changes.

“Of course I googled it, and nasal dermoid cyst came up. It is super rare, but it fit with Jude’s characteristics,” Lindsay says.

Preparing for a craniotomy

Nasal dermoid cysts occur in 20,000 to 40,000 births, forming while a baby is still an embryo. Most can be removed by an ear, nose, and throat (ENT) doctor with endoscopic instruments via the nostril. Yet in up to 10 percent of cases, a tract forms that extends into the brain. When this happens, the standard course of treatment is a craniotomy to separate the fingers of the cyst from the brain’s dura—a membrane that serves as the floor between the nose and the skull.

An MRI revealed that baby Jude was part of that 10 percent. To add concern, the cyst continually became infected, raising the risk of meningitis—a deadly brain infection. That’s when the family sought care at Stanford Medicine Children’s Health with Kelly Mahaney, MD, pediatric neurosurgeon. Because of the COVID-19 pandemic, they met virtually.

Bold alternative proposed

“It was incredibly frightening, but Dr. Mahaney was very reassuring,” Lindsay says. “She operates on children all of the time, and opening up skulls and working inside is what she specializes in, so I put my trust in her.”

During the pre-op appointment, the couple got a surprise. They were expecting to meet with Dr. Mahaney to discuss the craniotomy, but a second doctor joined in—Mai Thy Truong, MD, an ENT. The two had an interesting proposal: teaming up to remove the nasal dermoid cyst and its cranial extensions intranasally, or through the nose.  

“We usually wait to remove nasal dermoid cysts until children are at least 2 years old, so this was definitely pushing the envelope,” says Dr. Truong.

The surgery took place in late April of this year, just days before Jude turned 11 months old. It’s not very common for a neurosurgeon and an ENT to collaborate in this way. Yet it’s par for the course at Stanford, known for its interdisciplinary, collaborative spirit. Because Stanford Medicine Children’s Health is connected to an adult hospital, Stanford Hospital, there’s deep expertise readily available for consultation and support.

“We are empowered to challenge the status quo and push the limits to provide the very best care for our patients,” says Dr. Mahaney. “We take risks. We never put patients at risk, but we push our own limits to improve their outcomes.”

Successful surgery during COVID-19 pandemic

Jude’s surgery took nearly 10 hours to perform and was complicated by the timing during the pandemic. Nasal surgeries are especially risky during a pandemic because viruses can quickly become airborne. Jude was tested for COVID-19 before the surgery, and extra protocols were taken in the operating room, including N-95 masks over regular masks and extra personal protective equipment.

The two doctors worked side by side, ready to switch to a craniotomy if needed. Since nasal endoscopic instruments don’t come in baby size, Dr. Truong had to use ones designed for the ears.

“We were all amazed by how tiny his nose was,” she says. “It made the surgery extra challenging because everything was so close together.”

Dr. Mahaney assisted with imagery guidance and critical decision-making. Once the surgery was underway, Dr. Truong discovered a second cyst at the base of Jude’s brain, which looked like a tract of the original cyst on imagery but was actually separate. The two doctors discussed next moves step by step, intricately picking apart the cysts’ fingers from the brain’s dura.

“Dr. Truong has incredible patience to work through a baby’s little nostril for hours upon end. We were exhausted; I can only imagine how exhausted she felt,” Lindsay says. “Yet she was so confident, we felt confident.”

Peace of mind for parents

Lindsay was struck by what a good team the doctors made. She said both were very present and determined to remove every single piece of the two cysts. That gives her peace of mind that a cyst won’t grow back.

“We are so thankful that he didn’t need to have his skull opened. It made for a much easier recovery,” Lindsay says. “The next morning, he woke up and gave me a big smile.”

Today, Jude’s doing great—spending his days laughing and playing with his older siblings, Levi and Jane. In a few months, he will have a follow-up MRI to see if the cyst has grown back. Lindsay hopes and prays for proof that the doctors removed every last residual cyst cell with their meticulous work.

The purple lines are long gone, but Lindsay and Jeff’s gratitude is permanent.