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MUSC Otolaryngology - Head & Neck Surgery E-Update                 February 2016 
 Greetings and Happy New Year!

The MUSC ENT E-Update is back as requested and kicks off with our first 2016 article by one of our six new faculty members, Clarice S. Clemmens, M.D., Pediatric Otolaryngologist.
    
These newsletters are designed to provide brief, practical, clinical updates in areas where we all struggle in managing our patients. Your feedback or questions about the E-Update articles, your patients, or any other ENT issue are always welcome. Write to us at [email protected] - And please forward this E-Update to your colleagues who may also benefit from sharing the latest ENT topics. As always, your support is deeply appreciated.

Yours sincerely,
Paul R. Lambert, M.D.
Professor and Department Chair

Button Battery Ingestion
Clarice S. Clemmens, M.D.

The number of button battery ingestions resulting in severe injury or death has increased dramatically over the past thirty years. Rapid diagnosis and treatment are critical in preventing extensive injury, and close follow-up is required as delayed complications can occur weeks to months after button battery removal. 

Figure 1. (A) AP chest x-ray of button battery in the esophagus showing the "double ring" or "halo sign." (B) Lateral chest x-ray of button battery with "step off."
Foreign body ingestions are very common in the pediatric age group, particularly in those children aged 0 - 5 years. While the ingestion of many foreign bodies can be managed on a non-emergent basis, the ingestion of button batteries results in rapid and often catastrophic injuries. From 1985 - 2009, a 6.7-fold increase in the percentage of button battery ingestion with severe and fatal outcomes has been reported, with outcomes notably worse in children younger than four years old. Button batteries are ubiquitous, and their ingestion has become an increasingly encountered emergency associated with the increasing use of 3V 20-mm Lithium button batteries. 36.2% of reported cases of 20 mm lithium battery ingestions were from remote control devices, with a significant percentage of batteries also intended for games and toys, watches and stopwatches, flameless candles, bathroom and kitchen scales, and key fobs.   While batteries less than 15 - 18 mm in diameter generally pass through the esophagus and rarely require removal, the large size of the 20 mm batteries results in a propensity to become lodged within the esophagus, and the increased power results in more severe injuries. In fact, 94% of severe injuries or fatalities related to battery ingestion involved batteries greater than 20 mm in diameter.

Button batteries produce injury by three mechanisms: (1) the generation of an external electrolyte current resulting in electrolysis of tissue fluids and the generation of hydroxides at the battery's negative pole, (2) leakage of alkaline fluid, and (3) pressure necrosis. The generation of current is the primary mechanism by which button batteries cause injury. This mechanism is particularly important in the case of 20 mm lithium batteries, as these batteries do not contain an alkaline electrolyte and generate twice the current. These injuries occur rapidly, within two hours of ingestion, and are serious or fatal in up to 13% of cases.

Foreign body ingestions are often unwitnessed, and the symptoms of button battery ingestion are often nonspecific. They include cough, fever, decreased oral intake, difficulty swallowing, sore throat, and vomiting. These nonspecific complaints often result in a delayed diagnosis and further tissue damage. AP and Lateral x-ray imaging is essential in diagnosing button battery ingestion (Figure 1). In the AP view, a "double ring" or "halo sign" distinguishes a button battery from a coin. In the lateral view, a "step-off" can be noted with some batteries, however not all batteries will have a step-off. If the narrower portion of the battery can be identified on lateral x-ray, this information is important clinically, as the narrow portion of the battery is the negative pole and thus the site of primary damage.   The 3-N's mnemonic, "Negative-Narrow-Necrotic," is a reminder of this phenomenon.

Figure 2. Esophageal injury after removal of a button battery (A) resulting in a tracheoesophageal fistula (B).
Current National Battery Ingestion Hotline (NBIH) guidelines focus on a 2-hour window during which diagnosis and removal should be performed to minimize esophageal damage. Given the nonspecific nature of presenting complaints, it is imperative that health professionals maintain a high index of suspicion for button battery ingestion. Once the diagnosis is made, rapid removal of the battery within two hours results in the best outcome for patients and should not be delayed even if the patient has recently eaten. Endoscopic removal with direct visualization and optical forceps is recommended, as blind passage of an endoscope can result in significant injury. Assessment of the extent of injury and the location of the negative pole should be noted at the time of initial surgery. This will allow the surgeon to anticipate immediate and delayed complications resulting from the injury (Figure 2). In addition to esophageal injury, tissue necrosis may extend beyond the esophagus and result in vocal cord paralysis from recurrent laryngeal nerve involvement, thyroid hemorrhage, tracheoesophageal fistula, esophageal perforation, tracheal stenosis or tracheomalacia, mediastinitis, pneumonia, pneumothorax, spondylodiscitis, and aortoesophageal or other major arterial branch fistulas.

Delayed complications occur often after removal of button batteries, sometimes presenting days to weeks after the initial insult.   The most frequently encountered fatal complication is fistualization into a major artery, which has been reported to occur as late as 28 days after battery removal. While no follow-up imaging guidelines currently exist for these situations, contrast enhanced CT or MRI are often useful to assess for progression of injury and proximity to major blood vessels.

Ultimately, button battery ingestions with serious or fatal injuries have become more common. Unfortunately, delayed diagnosis in the setting of rapid tissue necrosis often results in advanced injuries at the time of surgical removal. Continued education and prevention efforts are absolutely necessary to avoid the often-devastating consequences of button battery ingestion.

References
  1. Sharpe S., Rochette l., Smith G. Pediatric Battery-Related Emergency Department Visits in the United States, 1990-2009. Pediatrics. 2012. 129(6)
  2. Jatana K., et. al. Pediatric button battery injuries: 2013 task for update. International Journal of Pediatric Otolaryngology. 2013. 77(9).
  3. Litovitz T., et. al. Emerging battery ingestion hazard: Clinical implications. Pediatrics. 2010. 125(6): 1168-1177
Clarice S. Clemmens, M.D.

Assistant Professor, Pediatric ENT

M.D.: Medical University of South Carolina
Residency: Hospital of the University of Pennsylvania
Fellowship: Children's Hospital of Philadelphia
Special Interests: Pediatric ENT, neonatal airway disorders, thyroid disorders, head and neck masses, and pediatric otology
Email: [email protected]

E-Update Articles 
Look for these articles in upcoming issues!

March:
Computer-assisted design and modeling in reconstruction of the head and neck: from virtual reality to reality

April: Otology - Neurotology 
   
May: Dynamic re-animation options for facial paralysis


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