Successful management of a delayed presented button battery ingestion in a toddler: A case report and literature review

Key Clinical Message

It is important to note that prevention of button battery ingestion is the most effective way to reduce its incidence and complications. This is unachievable without providing educational plans for parents. Moreover, triage nurses and first-line staff who take the history of patients and physicians should take the history to evaluate the risk of battery ingestion. Plain radiographs can be helpful in this matter, as the presence of "Hallow" and "Steep" signs in the anteroposterior and lateral views, respectively, can help.

Abstract

Foreign body ingestion is a relatively common occurrence in pediatrics, especially among children 1-3 years of age. Although most cases are benign and managed conservatively, those with high-risk subjects such as button batterie can bring about fatal conditions in the minority of cases. In the present study, the history, diagnostic, and therapeutic procedures of a 13-month-old baby with the final diagnosis of button battery ingestion are presented. The parents ignored the symptoms, suspecting that it was a viral infection. The evaluations showed that a battery was lodged in the middle part of the thoracic esophagus, which was removed by an urgent endoscopic procedure. The patient was under observation and on a nothing-by-mouth diet for a week, receiving nutritional fluid with a nasogastric tube. The necrosis, which was obvious after the removal of the battery, was healing in the second control esophagogastroduodenoscopy performed 1 week after the procedure. The stricture was minimal, and no need for dilation was diagnosed. This case report underscores the importance of a timely diagnosis and removal of these cases. This case underscores the importance of the timely presentation of these cases to health care and the risk of delayed removal, such as necrosis, forming fistula, and perforation of the esophagus. The delay can cause necrosis, fistula, and perforation and might lead to irreversible severe complications and even death.

Evaluating the management timeline of tracheoesophageal fistulas secondary to button batteries: A systematic review

INTRODUCTION

During the SARS-CoV-2 pandemic, the incidence of pediatric button battery (BB) ingestions has risen. Children have spent more time at home from school, while many parents try to balance working from home and childcare. Additionally, the amount of electronics powered by BB has increased. Tracheoesophageal fistula (TEF) secondary to a retained aerodigestive BB is a devastating development. Management is challenging, and the clinical timeline of watchful waiting versus surgical intervention for TEF is poorly defined in the literature.

METHODS

In accordance with PRISMA guidelines, databases searched include PubMed, Scopus, and CINAHL from database date of inception through August 13, 2021. All study designs were included, and no language, publication date, or other restrictions were applied. Case series and reports of TEFs secondary to BBs were included. Clinical risk factors and outcomes were compared between the spontaneous closure and surgical repair groups.

RESULTS

A total of 79 studies with 105 total patients were included. Mortality was 11.4%. There were 23 (21.9%) TEFs that spontaneously closed and 71 (67.6%) that underwent surgical repair. Median time to spontaneous closure compared to surgical repair was significantly different (8.0 weeks [IQR 4.0-18.4] vs. 2.0 weeks [IQR 0.1-3.3], p<0.001). Smaller TEFs were more likely to spontaneously close versus being surgically repaired (9.3 mm ± 3.5 vs. 14.9 mm ± 8.3, p=0.022). Duration of symptoms before BB discovery, BB size, time between BB removal and TEF discovery, and location of the TEF were not statistically different between the spontaneous closure and surgical repair groups.

CONCLUSION

A TEF secondary to BB ingestion is a potentially deadly complication. Timing of reported TEF spontaneous closure varies significantly. While smaller TEFs may be amenable to healing without surgical repair, no other significant factors were identified that may be associated with spontaneous closure. If clinical status permits, these data suggest a period of observation of at least 8 weeks prior to surgical intervention may be practical for many BB-induced TEFs.

Airway Complications Resulting From Pediatric Esophageal Button Battery Impaction: A Systematic Review

Importance

Button batteries (BBs) are commonly found in many household items and present a risk of severe injury to children if ingested. The direct apposition of the trachea and recurrent laryngeal nerves with the esophagus puts children at risk of airway injury secondary to the liquefactive necrotic effects of BB impactions.

Objective

To review airway injuries, including long-term sequelae, after BB ingestion in children.

Evidence Review

For this systematic review, a comprehensive strategy was designed to search MEDLINE, Embase, Cochrane Database of Systematic Reviews, Web of Science, and CINAHL (Cumulative Index of Nursing and Allied Health Literature) from inception to July 31, 2021, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Additional cases were identified from the National Capital Poison Center BB registry. Individual authors were contacted for additional information. Studies with pediatric patients (<18 years) who developed airway injuries after BB ingestion were included. A total of 195 patients were included in the analysis; 95 were male. The mean (SD) age at BB ingestion was 17.8 (10.2) months. The mean (SD) time from BB ingestion to removal was 5.8 (9.0) days. The 2 most common airway sequelae observed in our series were 155 tracheoesophageal fistulae and 16 unilateral vocal cord paralyses. Twenty-three children had bilateral vocal cord paralysis. The mean (SD) duration of ingestion leading to vocal cord paralysis was shorter than that of the general cohort (17.8 [22.5] hours vs 138.7 [216.7] hours, respectively). Children presenting with airway symptoms were likely to have a subsequent tracheoesophageal fistula or vocal cord paralysis.

Conclusions and Relevance

Airway injuries are a severe consequence of BB ingestion, occurring more often in younger children. This systematic review found that tracheoesophageal fistulae and vocal cord paralyses were the 2 most common airway injuries, often requiring tracheostomy. Vocal cord injury occurred after a shorter BB exposure time than other airway injuries. Continued efforts should be directed toward prevention strategies to avoid the devastating sequelae of BB-associated airway injury.

Evolving Trends of Button Battery Ingestion in Indian Children at a Tertiary Care Hospital

INTRODUCTION

Foreign body ingestion is a common problem encountered in the pediatric age group. Impaction of lithium batteries of greater than 20-mm diameter in the esophagus is associated with severe complications. This study aimed at analyzing the evolving trends of button battery ingestion in pediatric age groups at our tertiary care center in terms of clinical presentation, intraoperative findings, and the correlation of various clinical variables.

METHODS

A retrospective observational study was done. All children younger than 18 years with impaction of a button battery of size greater than 20 mm in the esophagus between January 2015 and December 2018 were included in the study. All children underwent removal of the battery using direct laryngoscopy/rigid esophagoscopy under general anesthesia.

RESULTS

There were 100 children included in the study with a mean age of 29.92 months having 93 children (93%) younger than 6 years. The mean duration of impaction was 34.7 hours. Increased duration of impaction was associated with an increased risk of complications and an increased difficulty in removal. There was a significant correlation between the site of impaction and the age of the patient. Complications were seen in 10% of cases with severe complications in 6 cases. No fatalities were reported in this study.

CONCLUSIONS

Button batteries impacted in the esophagus can lead to severe complications including death. There has been an increasing trend in the ingestion of button batteries over the last 4 years. A prompt diagnosis and emergent removal of the battery are crucial to minimize the rate of complications. Symptoms of stridor and dysphagia must be given more attention, and these children are prioritized because they are more prone to have complications. Furthermore, primary prevention and caregiver education should be emphasized, and the need for a legislation to change the policies for securing the batteries in their products must be endorsed.

A novel approach to button battery removal in a two-and-half year-old patient's esophagus after ingestion: a case report

Background

Accidental swallowing of a foreign body occurs more frequently in children than in adults. Among these cases, button battery impaction in the esophagus may cause severe complications. While prevention is always ideal, if button battery impaction is suspected, immediate diagnosis and retrieval are important.

Case presentation

We introduce a novel method for retrieval of a button battery after ingestion by a 2.5-year-old child. When the patient arrived at our center, the battery was incarcerated in the upper esophagus. The battery could not be removed, despite the use of several methods such as alligator forceps under endoscopy and net retrieval. We decided to use a novel method that combined endoscopic balloon extraction and forceps retrieval. This resulted in a push-and-pull effect, creating synergy and easy removal of the battery. There were no long term complications based on the follow-up endoscopy examination.

Conclusions

This new procedure was very effective for removing the esophageal foreign body. When button battery in esophagus was too tight to be removed by the traditional retrieval methods, this procedure was suggested to use. It could be performed at medical institutions. If it fails or esophageal perforation (iatrogenic or spontaneous) occurs, pediatric surgeons could take over immediately.

Button Batteries and High-Powered Neodymium Magnet Ingestion in Children

BACKGROUND: Foreign body ingestions in pediatrics are present highly variably. For each case, it is important to consider the size of the child, the age of the child, the size of the object, and the inherently different risk of different objects ingested. It is important to note that regardless of the type of object, any foreign body should be removed from the esophagus. Over the past decade, the medical literature has particularly identified the potential for morbidity and mortality in cases of button battery and magnet ingestions. AIM: This study aims to describe the complications and how to avoid them in addition to studying the role of early endoscopic intervention in cases of button batteries (BB) and multiple magnets ingestion in children. METHODS: There were 151 children enrolled in the study, classified into two groups. The first group constitutes ninety children with BB, the other group sixty children with multiple magnets ingestion. In addition to one patient with both multiple magnets and battery ingestion, which are extracted endoscopically from the stomach without complication. BB detected in the upper gastrointestinal tract (GIT) in the esophagus, stomach, and duodenum in 70 patients were extracted endoscopically. Other 20 patients where the batteries were detected distal to duodenum were observed till the discharge of batteries was confirmed. In patients with multiple magnets, the magnets were in the upper GIT in 46 patients while found distal to the duodenum in 14 patients. RESULTS: There were 151 children enrolled in the study, classified into two groups. The first group constitutes ninety children with BB, the other group sixty children with multiple magnets ingestion. In addition to one patient with both multiple magnets and battery ingestion, which are extracted endoscopically from the stomach without complication. BB detected in the upper GIT in the esophagus, stomach, and duodenum in 70 patients were extracted endoscopically. Other 20 patients where the batteries were detected distal to duodenum were observed until the discharge of batteries was confirmed. In patients with multiple magnets, the magnets were in the upper GIT in 46 patients while found distal to the duodenum in 14 patients. CONCLUSION: This study put alarm that multiple magnets ingestion carries a high risk of gastrointestinal perforation compared to battery ingestion. Invitation to ban on the sale of products with high-powered neodymium magnets, such as Buckyballs and Buckycubes, and to keep BB difficult reachable by children. In addition to encouraging urgent endoscopic management of suspected BB or multiple magnets ingestion.

Therapeutic dilemma and clinical issues in management of the button battery ingestion: a case report and literature review

The incidence of button battery ingestion in children less than 6 years, from year 1985 to 2019 was 59,000 and it is still a clinical challenge for pediatricians. Objects which are commonly ingested are large amounts of food, coins, toy parts, jewels, batteries, sharp materials and non-metallic sharp objects. It is an increased incidence of mortality and morbidity due to button battery ingestion, compared to accidental ingestion of other objects, due to its small size, and because of its potent source of energy. A literature search was carried out to evaluate the challenges in diagnosing, treatment, and follow-up of button battery ingested cases in children. A total of 36 original articles were included for the review.

Conclusions: Button batteries can quickly cause severe damage to the mucosal lining of the GI tract. Esophageal button batteries require emergency removal because they can cause serious complications leading to hemorrhage, and death. In children, where the button battery has passed the esophagus watchful management should be made. In the majority of cases, the button batteries with a diameter less than 2 cm lodged in the stomach will pass spontaneously with no complications. However, asymptomatic children may be followed up with X-rays to assess progression up to 10–14 days after ingestion. Endoscopic or surgical removal may be required to prevent intestinal perforation with peritonitis. Symptomatic children will always need a consultation with a pediatric surgeon for surgery no matter where the button battery is placed in the GI tract. Developing countries shall adopt surveillance and reporting systems for BBI ingestion and related complications and it is recommended as essential to have management protocols in place for button batteries ingestion.

Current management of button battery injuries

Button batteries (BB) are found in common household items and can lead to significant morbidity and mortality in the pediatric population when ingested. BBs are made of various chemistries and have a unique size and shape that yield significant injury when lodged in the pediatric esophagus. BBs create a local tissue pH environment of 10 to 13 and can induce liquefactive necrosis at the negative pole. This initial injury can progress with further tissue breakdown even after removal. Unfortunately, patients may present with vague symptoms similar to viral illnesses and there is not always a known history of ingestion. Plain film X-ray can be diagnostic. Exposure can lead to caustic injury within 2 hours. Thus, timely endoscopic removal is the mainstay of treatment. Novel mitigation and neutralization strategies have been implemented into treatment guidelines. These include the preremoval ingestion of honey or sucralfate and intraoperative irrigation with acetic acid. Depending on the severity of injury following removal, careful consideration should be given for potential delayed complications including fistulization into major vessels which often leads to death. The National Button Battery Taskforce and several industry members have implemented prevention strategies such as educational safety outreach campaigns, child-resistant packaging changes, and warning labels. Governmental regulation and industry changes are key to limit not only the amount of BB ingestions, but also the devastating consequences that can result. Anonymous reporting of BB injuries through the Global Injury Research Collaborative has been made convenient and centralized through the advent of a user-friendly smartphone iOS/App Store and Android/GooglePlay application called the "GIRC App"; all specialists who manage foreign body cases should contribute their cases to help prevent future injuries. BB ingestion must be recognized and treated promptly using a multidisciplinary approach to optimize outcomes for these patients. Ultimately, a safer BB technology is critically needed to reduce or eliminate the severe and life-threatening injuries in children.

LEVEL OF EVIDENCE

5.

History and radiographic findings as predictors for esophageal coins versus button batteries

OBJECTIVE

To determine if clinical history and radiographic findings are reliable predictors for coin versus button battery in children presenting with esophageal foreign bodies to accurately guide decision making regarding the urgency of removal.

METHODS

A retrospective chart review was conducted in a single pediatric tertiary care center of all children who presented with suspected coin or button battery esophageal foreign body ingestion from 2017 to 2019. Patients with documented surgical removal, completed consultation notes, and available radiographic studies were included. Descriptive statistical analysis was performed and predictive characteristics of the diagnostic tests were calculated.

RESULTS

139 patients met inclusion criteria for the study. Of 5 patients who had esophageal button batteries removed, clinical history was concerning for button battery in 2; accuracy of 12.35%. However, radiology reports suggested a battery in all 5. The negative predictive value for radiology alone for diagnosis of button battery was 97% with 81% accuracy. The clinical history for coin foreign body was accurate in 85.28% while radiography was 87% accurate. Wait time on average for all coin foreign body cases was 6.3 h. Day cases waited on average 5.5 h while after-hours cases waited a statistically significantly longer 7.5 h (p = 0.006).

CONCLUSION

Button batteries, while clinically important emergencies, are rare esophageal ingestions. Radiography has a strong negative predictive value for button battery. Children whose radiographic studies do not demonstrate concern for button battery could be considered for delayed elective removal. This could allow children to complete a period of observation at home, thereby reducing prolonged in-house wait times prior to operative removal.

Gastric injury secondary to button battery ingestions: a retrospective multicenter review

BACKGROUND AND AIMS

Removal of gastric button batteries (BBs) remains controversial. Our aim was to better define the spectrum of injury and to characterize clinical factors associated with injury from retained gastric BBs.

METHODS

In this multicenter retrospective cohort study from January 2014 through May 2018, pediatric gastroenterologists from 4 pediatric tertiary care centers identified patients, aged 0 to 18 years, who had a retained gastric BB on radiography and subsequently underwent endoscopic assessment. Demographic and clinical information were abstracted from electronic health records using a standard data collection form.

RESULTS

Sixty-eight patients with a median age of 2.5 years underwent endoscopic retrieval of a gastric BB. At presentation, 17 (25%) were symptomatic. Duration from ingestion to endoscopic removal was known for 65 patients (median, 9 hours [interquartile range, 5-19]). Median time from ingestion to first radiographic evaluation was 2 hours. At endoscopic removal, 60% of cases had visual evidence of mucosal damage, which correlated with duration of BB retention (P = .0018). Time to retrieval of the BB was not statistically significant between symptomatic and asymptomatic subjects (P = .12). After adjusting for age and symptoms, the likelihood of visualizing gastric damage among patients who had BBs removed 12 hours post ingestion was 4.5 times that compared with those with BB removal within 12 hours of ingestion.

CONCLUSIONS

In this study, swallowed BBs posed a risk of damage to the stomach, including a single case of impaction and perforation of the gastric wall. Clinicians may want to consider retrieval within 12 hours of ingestion of gastric BBs. Larger prospective studies to assess risk of injury are needed.

Injury Mechanism of Button Batteries in the Nasal Cavity and Possible Mitigation Strategies During Impaction

OBJECTIVE/HYPOTHESIS

Button batteries (BBs) impacted in the nasal cavity can cause several complications. Understanding the injury mechanism and developing possible mitigation strategies can reduce these complications.

STUDY DESIGN

Cadaveric sheep nasal septum model.

METHODS

Lithium, alkaline, silver oxide, and zinc-air BBs were placed on segments of the nasal septum of cadaveric sheep. The BB voltage, tissue temperatures, and pH were measured every 30 minutes for 6 hours. Subsequently, 5 drops of lemon juice, apple cider vinegar, tea, Coke (Coca-Cola Co., Atlanta, GA), tap water, and normal saline were applied separately to the other segments with the lithium BBs every 10 minutes for 3 hours. The visible injuries and the necrosis depths were assessed through the tissue temperatures, pH, and the voltage changes.

RESULTS

Both nonlithium and lithium BBs increased tissue pH without significant temperature changes. The 3V lithium BBs led to the greatest depth of necrosis, with a voltage loss of approximately 50% within the first 2 hours. Lemon juice and apple cider vinegar were the most effective liquids for reducing visible injury, pH, and necrosis without increasing the temperature during pre-removal time period.

CONCLUSION

Nonlithium and lithium BBs caused alkaline tissue injury in a nasal septal model. Given the hazard severity, expedited BB removal is critical. For situations when removal cannot be immediately performed, further in vivo study is needed prior to considering human use of any pre-removal mitigation strategies in the nasal cavity.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:2487-2493, 2020.

Management and Outcomes of Button Batteries in the Aerodigestive Tract: A Multi-institutional Study

OBJECTIVES/HYPOTHESIS

To describe the clinical presentation, management, and complications associated with button battery impaction in the aerodigestive tract in children.

STUDY DESIGN

Retrospective case series.

METHODS

This multi-institutional study, endorsed by the American Society of Pediatric Otolaryngology research consortium, is a retrospective medical record review, including all children at five tertiary-care institutions presenting with button batteries impacted in the aerodigestive tract between January 2002 and December 2014. Battery type/size, duration and location of impaction, presenting symptoms, treatment, complications, and outcomes were examined.

RESULTS

Eighty-one patients were included (64.2% male), with ingestion witnessed in 20 (24.7%). Median age at presentation was 3 years (range, 1 week-14 years). Median time from diagnosis to removal was 2.5 hours (range, 0.4-72 hours). Locations included the esophagus (n = 48), hypopharynx (n = 1), stomach (n = 6), nasal cavity (n = 22), and ear canal (n = 4). Most common symptoms for esophageal/hypopharyngeal impactions included dysphagia (26.5%), nausea/vomiting (26.5%), drooling (24.5%), cough (18.4%), and fever (18.4%). Most common symptoms for nasal impactions included epistaxis (54.6%), rhinorrhea (40.9%), nasal pain (27.3%), and fever (22.7%). Almost all esophageal impactions were from 3-V (89.5%), 20-mm (81.8%) lithium batteries. Severe esophageal complications included stricture (28.6%), perforation (24.5%), tracheoesophageal fistula formation (8.2%), pneumothorax (4.1%), and bilateral true vocal fold paresis (4.1%). Nasal complications included necrosis (59.1%), septal perforation (27.3%), and saddle nose deformity (4.5%). Duration of impaction correlated with an increased likelihood of persistent symptoms only for nasal batteries (P = .049).

CONCLUSIONS

Button batteries in the upper pediatric aerodigestive tract or ear canal should be considered a surgical emergency, requiring urgent removal and careful vigilance for complications.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E298-E306, 2021.

The multi-disciplinary management of complex congenital and acquired tracheo-oesophageal fistulae

AIM OF THE STUDY

Complex tracheo-oesophageal fistulae (TOF) are rare congenital or acquired conditions in children. We discuss here a multidisciplinary (MDT) approach adopted over the past 5 years.

METHODS

We retrospectively collected data on all patients with recurrent or acquired TOF managed at a single institution. All cases were investigated with neck and thorax CT scan. Other investigations included flexible bronchoscopy and bronchogram (B&B), microlaryngobronchoscopy (MLB) and oesophagoscopy. All cases were subsequently discussed in an MDT meeting on an emergent basis if necessary.

MAIN RESULTS

14 patients were referred during this study period of which half had a congenital aetiology and the other half were acquired. The latter included button battery ingestions (5/7) and iatrogenic injuries during oesophageal atresia (OA) repair. Surgical repair was performed on cardiac bypass in 3/7 cases of recurrent congenital fistulae and all cases of acquired fistulae. Post-operatively, 9/14 (64%) patients suffered complications including anastomotic leak (1), bilateral vocal cord paresis (1), further recurrence (1), and mortality (1). Ten patients continue to receive surgical input encompassing tracheal/oesophageal stents and dilatations.

CONCLUSIONS

MDT approach to complex cases is becoming increasingly common across all specialties and is important in making decisions in these difficult cases. The benefits include shared experience of rare cases and full access to multidisciplinary expertise.

Characteristics and outcome of impacted button batteries among young children less than 7 years of age in China: a retrospective analysis of 116 cases

BACKGROUND

Ingestion of button batteries occurs in about ten persons per one million persons each year, with most of them children, and one in every 1000 battery ingestions leads to serious injuries. This study aimed to describe the clinical features and outcome of ingestion or inhalation of button batteries in children spanning a decade from January, 2006 to December, 2016 at a tertiary care hospital.

METHODS

We reviewed the clinical records of children who sought treatment for inhaled or ingested button batteries at our hospital during the study period. Data on gender, age, time from ingestion to treatment, site of impaction, imaging findings, and outcomes were retrieved and analyzed.

RESULTS

We identified 116 pediatric cases of ingestion or inhalation of button batteries. Their mean age was 26 months. The time from ingestion or inhalation of button batteries to treatment was 0.5 hours to 2 weeks. Ninety-seven (83.6%) button batteries were located in the nasal cavity, 13 (11.2%) in the gastrointestinal (GI) tract including 6 in the esophagus, and 7 in the stomach and lower GI tract, and 6 (5.2%) in the auditory tract. Twenty-one (21.6%) children with nasal button batteries had preoperative septal perforations and one (1.0%) had postoperative septal perforation. One child with esophageal button battery developed esophageal stricture and one died of sudden cardiac arrest perioperatively. One child had auditory damages in the right tympanic membrane and ossicles.

CONCLUSIONS

Inhalation or ingestion may occur in the nasal cavities, the esophagus and GI tract and the auditory tract. Prompt diagnosis and treatment are required for a satisfactory outcome and ingested or inhaled button batteries require different treatment protocols.

An uncommon source for oesophageal foreign body: Fidget spinner

Fidget spinner is a new handheld toy with potential choking and ingestion hazard. Our objectives are to describe clinical presentation of a child with fidget spinner ingestion and draw attention to danger associated with fidget spinner. A 3-year-old boy presented with painful swallowing and feeling of something stuck in the throat. A chest radiograph revealed a radiopaque foreign body with a disc-like component. Rigid oesophagoscopy revealed a foreign object with disc battery and battery holder circuit board. Clinicians should consider the fidget spinner as one of many varieties of toys that has potential for button battery ingestion or aspiration.