BackgroundEndoscopic skull base surgery (ESBS) is a rapidly expanding field. Despite divergent reported preferences for reconstructive techniques and perioperative management, limited data exist regarding contemporary practice patterns among otolaryngologists performing ESBS. This study aims to elucidate current practice patterns, primarily the volumes of cases performed and secondarily a variety of other perioperative preferences.MethodsAn anonymous 32‐item electronic survey examining perioperative ESBS preferences was distributed to the American Rhinologic Society membership. Statistical significance between variables was determined utilizing Student t, chi‐square, and Fisher exact tests.ResultsSeventy otolaryngologists completed the survey. The effective response rate was approximately 22.5%. Sixty percent of respondents were in full‐time academic practice and 70% had completed rhinology/skull base fellowships. Annually, 43.3 mean ESBS cases were performed (29.1 private practice vs. 52.9 academic practice, P = .009). Academic practice averaged 24.1 expanded cases versus only 11 in private practice (P = .01). Of respondents, 55.7% stood on the same side as the neurosurgeon and 72.9% remained present for the entire case. Current procedural terminology coding and antibiotic regimens were widely divergent; 31.4% never placed lumbar drains preoperatively, while 41.4% did so for anticipated high‐flow cerebrospinal fluid leaks. While considerable variation in reconstructive techniques were noted, intradural defect repairs utilized vascularized flaps 86.3% of the time versus only 51.3% for extradural repairs (P < 0.001). Major complications were rare. Postoperative restrictions varied considerably, with most activity limitations between 2–8 weeks and positive airway pressure use for 2–6 weeks. Most respondents started saline irrigations 0–2 weeks postoperatively.ConclusionsBased on responses from fellowship‐ and non‐fellowship‐trained otolaryngologists in various practice settings, there remains considerable variation in the perioperative management of patients undergoing ESBS.Level of Evidence5

Objective: To evaluate the association of weather, seasons, months and holidays on the frequency and pattern of pediatric facial fractures. Methods: Retrospective review of pediatric patients treated for facial fractures at two Level I trauma centers in a midsize Midwestern US city over a 5-year period. Patients were included only if presentation was within 3 hours of inciting trauma, transfers from other facilities were excluded. Demographic characteristics, fracture patterns, operative interventions, weather data, and local public school schedules were acquired and associations were analyzed with unpaired t tests, χ 2 , multivariate and binomial regression model analyses. Results: Two hundred and sixty patients were included. The average age (SD) was 11.8 (5.0) years, with 173 males and 87 females. The highest distribution of presentations occurred in the summer season (35.0%), on weekends and holidays (58.1%), and when the weather was described as clear (48.5%). The most common mechanisms of injury were motor vehicle collisions (25.8%), followed by sports-(21.5%) and assault-(16.5%) related injuries. Mechanisms were significantly associated with certain fracture patterns. Older age was associated with fewer orbital fractures (P < .01). Seventy-five patients (28.8%) required operative intervention. Age was found to impact the likelihood of operative intervention (Exp(β) = 1.081, P = .03) while weather, temperature, and mechanism did not. Conclusion: Pediatric facial fractures are linked to warmer weather with clear skies and warmer season. Age predicts some fracture patterns and need for operative intervention. These results can be used to inform public health interventions, policymaking, and trauma staffing. Level of Evidence: Level 2b (retrospective cohort).

Background Pediatric group A streptococcal peritonitis (GASP) is a rare but serious infection, with few cases reported in the literature. Utah has an unusually high incidence of invasive GAS (iGAS) disease, but the frequency and characteristics of pediatric GASP are unknown. Methods We performed a retrospective chart review to identify GASP in Utah children from 2000-2019. GASP was defined as isolation of GAS from peritoneal fluid or blood and clinical signs of peritonitis. Results : Eleven children with GASP were identified, with slight female predominance (n=6). Median age was 6 years; males were significantly younger than females (1.4 versus 7.2 years, p=0.01). GAS was isolated from 4 of 8 blood and 8 of 11 peritoneal cultures obtained. Peritoneal fluid PCR was positive for GAS in one patient. Ten patients underwent laparotomy. Peri-appendiceal inflammation prompted appendectomy in 7 patients; only one had pathologic findings of acute appendicitis. Four patients developed streptococcal toxic shock syndrome and 7 required intensive care. Non-white race (n=4) and lack of appendectomy (n=5) were associated with more severe outcomes. Median antibiotic duration was 27 days. Median hospitalization was 8 days. All patients survived. Figure 1. Schematic representation of GAS peritonitis patient clinical course. Each patient is represented by a single line. Duration of symptoms prior to hospitalization, as well as duration of hospitalization (day 0 representing admission), intensive care, antibiotic administration, and timing of procedural interventions are noted. Duration of antibiotics after discharge for patient 3 was unable to be verified, as indicated by a question mark. Hospitalization, general pediatric hospital care. PICU, pediatric intensive care unit. IR, interventional radiology. Conclusion We present the largest pediatric case series of GASP to date. Diagnostic hallmarks included gastrointestinal symptoms, fever, systemic inflammation, and peritoneal enhancement without an abdominal source. Peri-appendiceal inflammation was common, although acute appendicitis was rare, and appendectomy was associated with a less severe course. GASP should be considered in patients with acute abdominal processes given increasing incidence of iGAS infections. Disclosures All Authors: No reported disclosures