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BackgroundTracheostomies in children are associated with significant morbidity, poor quality of life, excess healthcare costs and excess mortality. The underlying mechanisms facilitating adverse respiratory outcomes in tracheostomised children are poorly understood. We aimed to characterise airway host defence in tracheostomised children using serial molecular analyses.MethodsTracheal aspirates, tracheal cytology brushings and nasal swabs were prospectively collected from children with a tracheostomy and controls. Transcriptomic, proteomic and metabolomic methods were applied to characterise the impact of tracheostomy on host immune response and the airway microbiome.ResultsChildren followed up serially from the time of tracheostomy up to 3 months postprocedure (n=9) were studied. A further cohort of children with a long-term tracheostomy were also enrolled (n=24). Controls (n=13) comprised children without a tracheostomy undergoing bronchoscopy. Long-term tracheostomy was associated with airway neutrophilic inflammation, superoxide production and evidence of proteolysis when compared with controls. Reduced airway microbial diversity was established pre-tracheostomy and sustained thereafter.ConclusionsLong-term childhood tracheostomy is associated with a inflammatory tracheal phenotype characterised by neutrophilic inflammation and the ongoing presence of potential respiratory pathogens. These findings suggest neutrophil recruitment and activation as potential exploratory targets in seeking to prevent recurrent airway complications in this vulnerable group of patients.

ObjectivesTo explore the experience of caring for children with tracheostomies from the perspectives of parents and health professional caregivers.DesignQualitative semistructured interview study.SettingOne region in England covered by a tertiary care centre that includes urban and remote rural areas and has a high level of deprivation.ParticipantsA purposive sample of health professionals and parents who care for children who have, or have had, tracheostomies and who received care at the tertiary care centre.InterventionInterviews undertaken by telephone or video link.Primary and secondary outcome measuresQualitative reflexive thematic analysis with QSR Nvivo 12.ResultsThis paper outlines key determinants and mediators of the experiences of caregiving and the impact on psychological and physical health and quality of life of parents and their families, confidence of healthcare providers and perceived quality of care. For parents, access to care packages and respite care at home as well as communication and relationships with healthcare providers are key mediators of their experience of caregiving, whereas for health professionals, an essential influence is multidisciplinary team working and support. We also highlight a range of challenges focused on the shared care space, including: a lack of standardisation in access to different support teams, care packages and respite care, irregular training and updates, and differences in health provider expertise and experiences across departments and shift patterns, exacerbated in some settings by limited contact with children with tracheostomies.ConclusionsUnderstanding the experiences of caregiving can help inform measures to support caregivers and improve quality standards. Our findings suggest there is a need to facilitate further standardisation of care and support available for parent caregivers and that this may be transferable to other regions. Potential solutions to be explored could include the development of a paediatric tracheostomy service specification, increasing use of paediatric tracheostomy specialist nurse roles, and addressing the emotional and psychological support needs of caregivers.

Paediatric tracheostomy is most commonly performed in children on the paediatric intensive care unit (PICU) to facilitate long-term ventilation. We sought to identify trends in UK tracheostomy practice in PICUs. Data were analysed from 250 261 admissions, including 4409 children tracheostomised between 2003 and 2017. The incidence of tracheostomy in 2017 was approximately half that in 2003 (incidence rate ratio=0.48, 95% CI 0.40 to 0.57). The percentage of patients tracheostomised during a PICU admission, as a proportion of all admissions, was 2.44% (n=319) in 2003 and reduced to 0.97% (n=180) in 2017. Nevertheless, we identified great variability in practice between different PICUs with tracheostomy rates between 0.0% and 4.0% of all admissions. Risk-adjusted PICU mortality was comparable between tracheostomised children and all admissions to PICU.

Objectives To explore the impact of the COVID-19 pandemic on the experiences of caregivers of children with tracheostomies. Design Qualitative semistructured interviews. Setting All participants were currently, or had previously cared for, a tracheostomised child who had attended a tertiary care centre in the North of England. Health professionals were purposively sampled to include accounts from a range of professions from primary, community, secondary and tertiary care. Participants Carers of children with tracheostomies (n=34), including health professionals (n=17) and parents (n=17). Interventions Interviews were undertaken between July 2020 and February 2021 by telephone or video link. Main outcome measure Qualitative reflexive thematic analysis with QSR NVivo V.12. Results The pandemic has presented an additional and, for some, substantial challenge when caring for tracheostomised children, but this was not always felt to be the most overriding concern. Interviews demonstrated rapid adaptation, normalisation and varying degrees of stoicism and citizenship around constantly changing pandemic-related requirements, rules and regulations. This paper focuses on four key themes: ‘reconceptualising safe care and safe places’; ‘disrupted support and isolation’; ‘relationships, trust and communication’; and ‘coping with uncertainty and shifting boundaries of responsibility’. These are described within the context of the impact on the child, the emotional and physical well-being of carers and the challenges to maintaining the values of family-centred care. Conclusions As we move to the next phase of the pandemic, we need to understand the impact on vulnerable groups so that their needs can be prioritised., For those with complex care needs the challenges of Covid-19 have been heightened. Caregivers of children with tracheostomies describe the pressures placed on trust, communication and relationships and the challenges of delivering family centred care.

A normally fit and well 3-year-old girl awoke distressed. Her parents identified a long hair protruding from her mouth. She was comforted and given some food and drink. Afterwards they could no longer see the hair and she had no ongoing pain or issues initially. Over the subsequent days, she had

What you need to know In many, tonsillitis is self-limiting and of relatively short duration. A subset of patients suffers from recurrent debilitating episodes, with impaired daily functioning and absence from work.1 Adult tonsillitis places a substantial burden on healthcare resources. Costs include primary care consultations, medical treatment, hospital admissions, and treatment of potentially life threatening complications.123 There are three approaches to the management of tonsillitis: conservative (wait and watch), antibiotics, or tonsillectomy. Tonsillectomy provides definitive treatment for recurrent tonsillitis and was performed on more than 17 000 adult patients in England in 2014-2015.4 Currently there is uncertainty around the severity of disease at which it is cost effective to perform tonsillectomy on adults with recurrent tonsillitis, as compared with conservative management. ### Search strategy and study selection We searched Medline, Embase, and the Cochrane Library using the terms “tonsillitis” or “tonsillectomy” or “pharyngitis.” We included studies that involved adults and were published in English between 1996 and February 2017 (table 1⇓). We found Cochrane reviews comparing antibiotics with placebo, and comparing tonsillectomy with watchful waiting. We also found a review of qualitative outcomes in tonsillectomy, two retrospective studies investigating complications of tonsillectomy, a cross-sectional study of the complications of tonsillitis and tonsillectomy rates, and a small cohort study observing economic outcomes pre and post tonsillectomy. View this table: Table 1 Summary of evidence for the treatment of recurrent adult tonsillitis In the UK, Clinical Commissioning …

A young woman presented with prominence of the dorsum of her nose since childhood. She had become increasingly self-conscious of her appearance but was otherwise fit and well. She denied symptoms of nasal obstruction, epistaxis or discharge but described an intermittent ache related to the lump. There was no history of seizures, meningitis or cerebral abscess. Examination revealed a firm midline dorsal hump (figures 1 and 2). The rest of the examination …

Persistent throat symptoms are common in adults. Globus pharyngeus (a feeling of a lump in the throat), dysphonia, throat clearing, cough, excessive phlegm, throat pain, and postnasal secretions are present in up to 25% of primary care attenders, and more than 60 000 people are referred to secondary otolaryngological care annually.1 Treating persistent throat symptoms with gastric acid suppression has been in vogue for more than a decade, on the basis that they represent “atypical” manifestations of gastro-oesophageal reflux disease (GORD).2 So called extraoesophageal reflux or laryngopharyngeal reflux is internationally acknowledged as a separate GORD subcategory from “typical” oesophageal reflux disease.3 However, the relation between gastric reflux and persistent throat symptoms, and the role of proton pump inhibitor (PPI) treatment remains controversial.4 5 More than half of UK otolaryngologists prescribe PPIs for persistent throat symptoms.6 The message has also filtered through to primary care that PPIs are a reasonable “empirical” treatment. PPI treatment is a substantial expense for healthcare systems and increasingly treatment of persistent throat symptoms is adding to this. The cost of PPI treatment to the National Health Service in England for all conditions, including persistent throat symptoms, was £425m (€540m; $694m) in 2006 and the global bill was £7bn.7 On 25 June 2014 we searched Medline and Embase databases and the Cochrane Library for studies dealing with persistent throat symptoms, gastric reflux, and treatment with PPIs. We used the search terms “throat symptoms” or “laryngopharyngeal reflux” or “extra-oesophageal reflux” or “extra-esophageal reflux” or “gastro-oesophageal reflux disease” or “gastro-esophageal reflux disease” or “proton pump inhibitors”. ### Are persistent throat symptoms atypical features of gastric reflux? The pathogenesis of persistent throat symptoms in gastric reflux is hypothesised to be through retrograde flow of gastric contents (particularly acid, bile, and pepsin) that affect the laryngopharynx by direct mucosal contact, or by a secondary mechanism.8 …