A two-year-old presents at a clinic with persistent cough and neck discomfort and winds up in the ED and eventually the operating room for endoscopic evaluation. Find out the culprit and the best practices to manage the diagnosis.
Figure 1a: PA chest radiograph demonstrating the double-ring sign
A 23-month-old female presented to a clinic with persistent cough and neck discomfort for more than one month. Additionally, she had difficulty swallowing solid foods but no trouble with liquids.
She was seen by her primary care provider over one month prior for the same symptoms. She was then started on albuterol and a five-day course of steroids, presumably for clinical suspicion of asthma. During a follow-up visit with the primary care provider, the patient’s symptoms remained unchanged, so she was given another course of steroids and had an outpatient chest x-ray. After review of the chest x-ray (figures 1a,b) the patient was immediately sent to the emergency department.
Figure 1b: Lateral neck radiograph demonstrating step-off between anode and cathode
In the emergency department, examination of the child revealed no acute distress, a pulse of 105, temperature of 97.7, respiratory rate of 24 with pulse oximetry of 97% on room air and a weight of 12.7 kg. Tympanic membranes were clear; oropharynx was clear without plaques or exudates; and the posterior oropharynx was symmetric. The neck was without nuchal rigidity but mild stridor was noted. No palpable masses or anterior cervical lymphadenopathy was appreciated. There was no murmur, rub or gallop. Pulmonary exam demonstrated diffuse rhonchi. Abdomen was soft, non-tender without distention. The skin was without rash, erythema, ecchymosis or wounds.
Figure 2: Esophageal tissue necrosis (black arrow) and granulation tissue (white arrow) post battery extraction (A: anterior; P: posterior)
ENT was consulted emergently and elected to take the patient directly to the operating room for endoscopic evaluation and removal of the foreign body. Visualization of the esophageal mucosa demonstrated surrounding granulation tissue and necrosis (figures 4 and 5). Repeat endoscopy on post procedural day three demonstrated esophageal stenosis. The patient was tolerating oral food and fluids and discharged home with plans to perform repeat endoscopy in two weeks. She was subsequently lost to follow up.
Figure 4: White arrow normal esophageal inlet; black arrow: granulation tissue; A: anterior pharyngeal wall; P: posterior pharyngeal wall
Figure 5: Extensive esophageal necrosis (white arrow); button battery (black arrow).
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Button Battery Ingestion Overview
The ingestion of small objects by children is common. The button or disc battery (pictured above, post removal) is one of the most worrisome objects because it can be easily swallowed. There may be as many as 15 battery ingestions per one million people each year in the United States. These objects represent a true emergency when they remain lodged in the esophagus because they may cause perforation in as short a period of time as two hours.
There are several mechanisms that may contribute to the damage done to surrounding tissues. These include electrical discharge of the battery at the negative pole leading to electrolysis of tissue fluids, leakage of alkaline battery contents leading to liquefactive necrosis and pressure necrosis. When the anode contacts the wall of the esophagus, it can raise the pH as high as 11. Most batteries will pass through the digestive tract spontaneously once they enter the stomach. When they remain lodged in the esophagus, this leads to major complications, including perforation, esophageal burns, fistula formation or even death.
The larger coin sized-batteries tend to impact at the cricopharyngeus. Risk factors for more serious adverse outcomes include ingestions of lithium batteries greater than 20 mm in diameter associated with increased current, new batteries, and length of time the object is in the esophagus. What saved the first child from sustaining more significant injury was probably that the battery was significantly discharged. Otherwise, the damage would have been much worse due to the prolonged presence of the battery in the esophagus.
How To Manage Button Battery Ingestion
Management of button battery ingestion begins with insuring cardiorespiratory stability. Many ingestion events are witnessed, and 80 percent of presenting patients are asymptomatic so often the first step will be localization of the object. Radiographs including anteroposterior views of the neck and CXR, and of the AP abdomen should be obtained. It is important to note that as much as 8.5 percent of ingestions involve multiple objects; therefore, complete imaging of the whole alimentary canal should be considered. Prompt differentiation between a coin and a battery is vital due to the difference in management. Button batteries require emergent endoscopy and removal whereas many coins may not. Button batteries will have a double ring or halo appearance on x-rays (figure 1a) due to their bilaminar structure.
This clinical description can be appreciated in a side-by-side comparison: button batteries have a notched edge whereas coins have a smooth appearance on-end. Another key feature when viewing the lateral images is the separation of the anode and cathode that appears as a step-off (figure 1b). Tissue necrosis and granulation tissue was seen once the battery was removed (figure 4). Several weeks later, a similar patient who also ingested a button battery presented to the emergency department, and much more extensive mucosal necrosis can be seen (figure 5).
1. Litovitz T, Whitaker N, Clark L, et al. Emerging battery-ingestion hazard: clinical implications. Pediatrics 2010; 125:1168.
2. Litovitz T, Whitaker N, Clark L. Preventing battery ingestions: an analysis of 8648 cases. Pediatrics 2010; 125:1178.
3. Sharpe SJ, Rochette LM, Smith GA. Pediatric battery-related emergency department visits in the United States, 1990-2009. Pediatrics 2012; 129:1111.