- Email: [email protected]
Button battery aspiration in children: Our experiences in a tertiary care teaching hospital of eastern India
PEPO 531 1–7 pediatria polska xxx (2017) xxx–xxx
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/pepo 1
Original research article/ Artykuł oryginalny
2
Button battery aspiration in children: Our experiences in a tertiary care teaching hospital of eastern India
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Q1
Santosh Kumar Swain 1,*, Shaswat Kumar Pattnaik 2, Alok Das 1, Mahesh Chandra Sahu 3 1
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, India 2 Department of Anesthesiology, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, India 3 Directorate of Medical Research, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, India
article info
abstract
Article history:
Background: Aspiration of button battery is in children is increasing in recent years due
Received: 11.02.2017
to more accessibility of electronic toys to the children. The electrochemical composition of
Accepted: 21.03.2017
button battery may cause extensive damage. It should be promptly and immediately
Available online: xxx
removed otherwise it leads to complications and death. Objective: To study the clinical
Keywords: Foreign body bronchus
design: A retrospective study. Methods: Six children those aspirated button battery and from the tracheobronchial tree during December 2012 to January 2017. Results: Button
button battery rigid bronchoscopy
matic after aspiration. One child came with stridor. The time interval between battery
presentations and outcome of the button battery aspiration among the children. Study underwent rigid bronchoscopy with spontaneous ventilation and followed by removal battery aspiration is common among male child in our study. All children were symptoaspiration and attending hospital was 25.33 h. Out of six patients two shows button battery in left bronchus, three in right bronchus and one is near the carina. Average hospital stay was 3.16 days. Conclusion: Early detection of such foreign bodies is essential to safe removal. Management approach has to be systematic. Preoperative history taking, radiological assessment followed by rapid intervention by skilled bronchoscopist usually results in favorable outcome. © 2017 Polish Pediatric Society. Published by Elsevier Sp. z o.o. All rights reserved.
12 13 14
Introduction
15
Aspiration of foreign body (FB) is a leading cause of death among children in the age group of 1–3 years [1]. Often death
occurs due to FB aspiration at the time of inhalation, but those reach the hospital and alive are less in number. Button battery ingestion is relatively rare occurrence and increasing in now days due to more accessibility of electronic toys to the children. One also except more incidence of button
* Corresponding author at: Department of Otorhinolaryngology, IMS & SUM Hospital, Kalinga Nagar, Bhubaneswar 751003, Odisha, India. Tel.: +91 9556524887. E-mail address: [email protected] (S.K. Swain). http://dx.doi.org/10.1016/j.pepo.2017.03.012 0031-3939/© 2017 Polish Pediatric Society. Published by Elsevier Sp. z o.o. All rights reserved.
Please cite this article in press as: Swain SK, et al. Button battery aspiration in children: Our experiences in a tertiary care teaching hospital of eastern India. Pediatr Pol. (2017), http://dx.doi.org/10.1016/j.pepo.2017.03.012
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battery aspiration, however few such reports have been reported [2]. This may be due several causes. Most of the aspirated FBs are food items whereas the batteries are unpleasant taste sensation which is usually expectorated or swallowed immediately. Children accesses to button batteries are often technically difficult as these are usually housed in devices which act as barriers. The rarity of FB aspiration is also due to the protection of airways with epiglottis, arytenoids and cough reflex. FB aspirations to the tracheobronchial tree are rare and fatal occurrences, more common among pediatric age group in emergency rooms. The common sites of FB impaction in tracheobronchial tree in order are right bronchus, left bronchus and trachea [3]. The smooth and shiny appearance of button battery often attractive to the children and they eagerly pick and handle them [4]. Button battery FBs are always have fatal outcome to the human being due to their chemical composition [5, 6]. FB aspiration is a fatal accident in children, especially during 3– 4 years age group and is a common etiology of morbidity and mortality [7]. The button batteries are commonly used in hearing aid, watches, toys or games and calculators. After lodgment of button batteries, lead to rapid tissue damage. Early detection of button batteries in airways is the key behind the protection of fatal outcome. Our study aims to describe the experiences of the clinical presentations, management and outcome of the button battery aspiration among the children in a tertiary care teaching hospital.
48
Materials and methods
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This is a retrospective study where six children with aspiration of button batteries attended the Department of Otorhinolaryngology in a tertiary care teaching hospital of eastern India during period of December 2012 to January 2017. The age, sex and presenting clinical features of the patient as well as imaging localization of the button batteries, interval between aspiration and clinical course followed by treatment were analyzed retrospectively. All patients were managed by rigid bronchoscopy. The composition, discharge state and type of the battery were not known for all aspirated children. Four patients were male child and two were female. Age ranged from 1 year to 6 years. Institutional ethical committee approved our study. A thorough history was taken with accidental inhalation of battery into the airways along with clinical symptoms like cough, chocking sensation and breathing difficulty. Proper head and neck examination along with appropriate radiological evaluation were done for the diagnosis of button battery in the tracheobronchial airways. The button batteries were removed on the emergency basis under general anesthesia. Brief clinical profiles of the six patients are given below.
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Case 1
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A 13-month-old female baby brought to the emergency department after 6 hours of sudden onset of dyspnea and cough. Parents of baby were not able to provide any source of FB ingestion. A chest radiograph showed a metallic FB in the lower airway. CT scan of the thorax confirmed a disc shaped
Fig. 1 – CT scan of the thorax showing button battery in the left bronchus
metallic FB at the lower part of the left bronchus (Fig. 1). Patient was immediately shifted to operation theater and underwent rigid bronchoscopy under general anesthesia with 2.5 mm size in diameter. The FB (Fig. 2) was removed without any complications with the help of telescopic optical bronchial FB forceps. The postoperative period of the child was uneventful. The chest X-ray was done on second day and found to be normal. The child was discharged after 72 hours.
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Case 2
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A 4-year-old boy was seen in the emergency department with history of button battery ingestion 24 hours before presentation. After ingestion, he was presenting with cough and shortness of breath. Chest X-ray confirmed the metallic disc shaped FB in the right bronchus. The patient was urgently shifted to the operation theater for removal of FB. He underwent rigid bronchoscopy with spontaneous ventilation via attached port of rigid bronchoscope. The button battery was removed. There was necrosis of the mucosa of the bronchus due to button battery (Fig. 3a and b), may be due to rapid release of chemicals from the battery. Postoperatively patient developed bronchospasm and managed with steroid nebulisation and steroid injection. He recovered and shifted to pediatric intensive care unit for observation. He was discharged after 5 days of hospital stay.
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Please cite this article in press as: Swain SK, et al. Button battery aspiration in children: Our experiences in a tertiary care teaching hospital of eastern India. Pediatr Pol. (2017), http://dx.doi.org/10.1016/j.pepo.2017.03.012
PEPO 531 1–7 pediatria polska xxx (2017) xxx–xxx
3
Fig. 2 – Button battery after recovery from the bronchus
Fig. 4 – Chest X-ray showing radiopaque foreign body with characteristic halo sign which is typical of a button battery
Fig. 3 – Endoscopic picture showing necrosis of the mucosa of bronchus (a) and button battery (b) after its removal
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Case 3
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A 19-month-old male child presented with history of swallowing a button battery since one day. The child was presenting with cough and breathing difficulty after swallowing of battery. X-ray chest revealed a disc shaped metallic FB in the right bronchus and its location again confirmed by CT scan of thorax. Immediately patient shifted to the operation room and rigid bronchoscopy was done under general anesthesia. Battery was removed from the right bronchus by telescopic optical bronchial FB forcep. Postoperative recovery of the patient was uneventful and discharged after 48 hours.
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Case 4
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A 3-year-old girl child referred to out patient Department of Otorhinolaryngology for sudden onset of cough and dyspnea with complaints of aspiration of FB. There was history of
accidental inhalation of a battery from hearing aid. Patient came after 72 hours of aspiration of FB. On clinical examination, child was presenting breathlessness, stridor and coughing. On chest auscultation, there was reduced air entry into the left lungs. On examination, nose, ear, oral cavity, oropharynx and neck are within normal limit. Immediately X-ray of the neck and chest were done, showed a radioopaque foreign body at the lower trachea (Fig. 4) which was confirmed by CT scan of the thorax. Since the child was dyspneic and with stridor, bronchodilators started and he was immediately taken to operation theater for rigid bronchoscopy under general anesthesia. The FB was successfully removed out by rigid ventilating bronchoscopy and optical forcep from the trachea near the carina without any complications. The patient was given antibiotics and nebulisation with bronchodilators. The child was discharged after 48 hours.
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Case 5
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A 5-year-old boy aspirated a button battery leading to immediate breathing difficulty, restless and presenting cough. Two hours later, he came to emergency department of our hospital. A chest X-ray was done showing a metallic FB in the lower airway. CT scan of thorax confirmed it in the right bronchus and was also showing collapse of the right lobe of lungs. His oxygen saturation dropped to 60– 70%. Immediately he was shifted to operation room. Rigid bronchoscope size 4.5 mm, length 30 cm with attached port for spontaneous ventilation was used for bronchoscopy
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Please cite this article in press as: Swain SK, et al. Button battery aspiration in children: Our experiences in a tertiary care teaching hospital of eastern India. Pediatr Pol. (2017), http://dx.doi.org/10.1016/j.pepo.2017.03.012
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Fig. 5 – CT scan of the thorax showing a radio-opaque foreign body (button battery) in the left bronchus
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procedure. Rigid bronchoscope showed a button battery completely blocking right bronchus, which was again confirmed by optical forceps. After two to three trials, FB was removed by grasp forceps. The patient discharged after 72 hours.
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Case 6
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A 20-month-old female baby was admitted to the department of Otorhinolaryngology for acute onset of dyspnea and cough. There was history of button battery aspiration one day back. The baby was afebrile and conscious. Baby had tachypnea with respiratory rate 52/minute and pulse oximetry showing oxygen saturation of 94% in air. Air entry was reduced in left side of chest on auscultation but there was no cyanosis. Chest X-ray was showing a small circular metallic FB in the left bronchus. The exact location and FB
was again confirmed from the CT scan of the thorax (Fig. 5). Immediately planned for rigid bronchoscopy and shifted to the operation room. In the first attempt of surgeon, the foreign body could not located and oxygen saturation fell down to 60%. Second attempt was made after making oxygen saturation to 100% and button battery was seen in lower part of the left bronchus and removed with the help of grasping forcep. After foreign body removal, air entry into left side of chest was started. The patient was discharged after 4 days.
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Anesthesia
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The objective of the anesthesia during bronchoscopy period is always maintaining spontaneous respiration throughout the procedure. All patients were pre-oxygenated with 100% oxygen for 5 min. The premedication used are injection glycopyrrolate (10 mg/kg IV), injection midazolam (0.04 mg/kg IV), injection fentanyl (1 mg/kg IV). Then the patient was sedated with propofol injection (2 mg/kg) and bag mask ventilation. The laryngoscopy was done and the trachea was sprayed with 1% lidocaine. Succinyl choline injection was given and once the patient was fully paralyzed, handed over to the surgeon for rigid bronchoscopy. The anesthesia circuit is connected to the side port of the rigid bronchoscope for ventilation. Sevoflurane was also used for maintenance via side port of the bronchoscope along with 100% oxygen. After successful rigid bronchoscopy procedure, the child were administered with 100% oxygen by mask and simultaneously nebulized with 1:10 000 adrenaline till complete awake of the child.
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Results
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Out of the 6 children, there were 4 boys and 2 girls in our study. The patient age ranged from 13 months to 5 years and the mean time from foreign body aspiration to treatment was 25.33 hours (2 to 72 hours). Postoperative recovery of children was uneventful except one case and X-ray chest done for assessing the proper expansion of the lungs. The right bronchus, left bronchus and trachea were the common sites for lodgment of button battery. Post-bronchoscopy complications occurred in one patient (Case 2) and that was bronchospasm. It was treated conservatively. There were no death occurred in our series. Detail clinical profiles of the patients are given in Tables I and II. Characteristics of button batteries and its injuries are given in Table III.
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Table I – Clinical profile and outcome of patients Patients 1 2 3 4 5 6
Age
Sex
Location
Removal interval
Hospital stay
Outcome
13 months 4 years 19 months 3 years 5 years 19 months
Female Male Male Female Male Male
Left bronchus Right bronchus Right bronchus Lower trachea Right bronchus Left bronchus
6 hours 24 hours 24 hours 72 hours 2 hours 24 hours
72 hours 5 days 48 hours 48 hours 72 hours 4 days
Successful Bronchospasm Successful Successful Successful Successful
Please cite this article in press as: Swain SK, et al. Button battery aspiration in children: Our experiences in a tertiary care teaching hospital of eastern India. Pediatr Pol. (2017), http://dx.doi.org/10.1016/j.pepo.2017.03.012
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in hearing aids, calculators, watches, cameras, glucometers, toys and many electronic instruments. These batteries are sealed and contain corrosive and toxic chemicals and heavy metals like mercury, silver, zinc, nickel, chromium, cadmium, lithium and manganese along with a concentrated alkaline electrolyte solution of 26% to 45% potassium or sodium hydroxide [10, 11]. These chemicals starts leaking if kept in contact with wet mucosal surface like mouth, esophagus or trachea. Prolonged contact with mucosa cause extensive damage. Detail electrochemical properties of button batteries are given in Table IV. The American Association of Poison Control Centers documented 476 cases of button or disc battery exposure to human being as foreign body where 59% had no morbidity, 9% had moderate to major morbidity without any death report in 2007[12]. Button batteries in gastrointestinal tract may pass without much complication although it depends on the size of the battery. The button battery in the tracheobronchial airways lodges and leads to devastating complications by rapid tissue destruction. The chemical composition of the disc batteries is alkaline corrosive materials or heavy metals. On the basis of the chemical composition, the disc batteries are classified into four types: mercury (consists of mercuric oxide and aqueous potassium hydroxide), manganese (consists of manganese dioxide and aqueous potassium hydroxide) and lithium manganese (consists of lithium and manganese dioxide). Lithium containing batteries are more dangerous and have the highest potential to cause extensive mucosal damage whereas the zinc containing batteries are least dangerous. The complications due to button or disc batteries aspiration or ingestion occur due to four types of mechanisms. These are leakage of alkali causing direct caustic injury of the tissue, absorption of toxic materials, electric discharge causing mucosal burns and pressure necrosis of the mucosa. One of our cases (case.2) was showing necrosis of the bronchial mucosa which may be
Table II – Clinical presentations and chest findings among six patients Clinical Presentation
Number of patients
Cough Wheezing Dyspnea Decreased air entry into lungs Abnormal pulmonary sounds Stridor
5 4 3 5 4 1
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Discussion
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Incidence of airway FBs is more common among children than adult. Often children explore their world by taking any objects into their mouth. The children have habit of putting objects in the mouth and assess the taste and texture. Often small children are taken care by elder siblings in village area. Negligence, illiteracy, mental infirmity, talking while eating, alcohol intoxication and wearing dental prosthesis are some important causes for FB aspiration. There are three phases of clinical presentation after FB aspiration. First phase of FB aspiration consists of gagging, chocking and coughing at the time of aspiration. Parents of the children will give history of this phase of clinical presentation if witnessed. The cough is a protective mechanism, gradually fatigued and ensures the second phase for few hours. Complications usually occur in the third phase when definite obstruction occurs or erosion or infections are associated [8, 9]. If FB stay for longer period, it results in granulation tissue, narrowing of airway and symptoms are aggravated [9]. Due to increase use of miniaturized electronic toys and equipments, the incidence of small size batteries aspiration appears to be increased. The button batteries are tiny disc shaped power units commonly used
Table III – Characteristics of button batteries aspirated by children Patients 1 2 3 4 5 6
Size of button battery (mm)
Type of battery
Surrounding tissue damage bay battery
10 12 15 20 12 15
Alkaline Alkaline Alkaline Alkaline Alkaline Alkaline
Mucosal burn Necrosis of surrounding tissue Mucosal burn Mucosal burn Mucosal burn and necrosis of adjacent tissue Mucosal burn
Table IV – Electrochemical properties of commonly available batteries Types of battery
Active chemical compound
Voltage (V)
Toxicity
Disposable
Zinc carbon Zinc manganese dioxide Lithium Mercury oxide Zinc air
1.5 1.5 1.5 1.35 1.35–1.65
Zinc causes corrosive reaction Alkali leak causes severe burn Cause severe caustic reaction
Nickel zinc Nickel cadmium Nickel metal-hydride Lithium-ions
1.6 1.2 1.2 3.6
Rechargeable
Commonly used battery Commonly used in hearing aid
Presently available in market
Please cite this article in press as: Swain SK, et al. Button battery aspiration in children: Our experiences in a tertiary care teaching hospital of eastern India. Pediatr Pol. (2017), http://dx.doi.org/10.1016/j.pepo.2017.03.012
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due to rapid release of alkaline materials from the battery. All our patients had a positive history of FB aspiration with presentation of coughing and chocking sensation. As airway FBs pose a life-threatening risk, especially in children, should be removed early without delay. Rigid bronchoscopy has several advantages for removal FB from airway. The advantages are better ability to ventilate the patient and also visualize and manipulation of the FB. The younger the patient, the greater the advantages of the rigid bronchoscopy. Delay in diagnosis of button battery in airway can lead to disastrous outcomes. All of our cases were not in such long-term squeal. Parents and the community at large should be educated properly regarding the risk of button batteries aspiration in children. FB like Button battery should be removed without delay only in a hospital well equipped with instruments and expert surgeon, anesthetists and medical staff experienced with bronchoscopy. Complications of repeated rigid bronchoscopy include laryngeal trauma, bleeding, laryngeal edema, laryngospasm, bronchospasm, tracheobronchial laceration, hypoxemia and pneumothorax [13]. Button battery aspiration is an emerging killer among pediatric patients worldwide. As the prompt surgical intervention is not always available to all patients, so in delayed cases button battery aspiration create a devastating outcome. It is always better to give preventive efforts for raising awareness among parents and public. There should be always warning labels apply to the batteries and electronic instruments along with instructions for treatment. Battery manufacturing company should educate the public regarding the potential hazard for button battery ingestion or aspiration. Battery manufacturing company should also urge to give more secured fastened and child resistant battery compartment.
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Conclusion
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The incidence of Button or disc battery ingestion is rising due to increase use of portable miniaturized electronic toys among children. Aspiration of button battery is a serious condition which is best treated by urgent rigid bronchoscopy. This type of FB aspiration in children could be prevented by parent education and public awareness. Although the button battery aspiration is rare incidence, pediatrician or physician who treat these children should be aware of the possible fatal and serious outcomes and facilitate the prompt intervention. In battery production industry, improved packaging and button battery markings will help to minimize morbidity among children.
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Study limitation
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This study has a relatively small sample size. However, the detail clinical presentations and management of the button battery aspiration will definitely give a management strategy and it's awareness among pediatrician, otolaryngologists, parents and public.
Authors’ contributions/ Wkład autorów
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According to order.
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Conflict of interest/ Konflikt interesu
313
None declared.
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Financial support/ Finansowanie
315
None declared.
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Ethics/ Etyka
317
The work described in this article has been carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) for experiments involving humans; EU Directive 2010/63/EU for animal experiments; Uniform Requirements for manuscripts submitted to Biomedical journals.
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references/ pi smiennictwo
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[1] Swain SK, Mohanty S, Sahu MC. Safe and effective anaesthesia during paediatric rigid bronchoscopy: an experience at a tertiary care centre of eastern India. Pediatr Pol 2015;90:470–473. [2] Moral L, Serna JV, Castillo B. Aspiration of a button battery: a unique case in the medical literature. Arch Bronconeumol 2010;46(3):153–154 [in Spanish]. [3] Figueiredo RR, Machado WS. Foreign body aspiration through tracheotomy: a case report. Rev Bras Otorrinolaringol 2005;71(2):234–236. [4] Lin VY, Daniel SJ, Papsin BC. Button batteries in the ear, nose and upper aerodigestive tract. Int J Pediatr Otorhinolaryngol 2004;68(4):437–479. [5] Hamilton JM, Schraff SA, Notrica DM. Severe injuries from coin cell battery ingestions: 2 case reports. J Pediatr Surg 2009;44(3):644–647. [6] Soerdjbalie-Maikoe V, van Rijn RR. A case of fatal coin battery ingestion in a 2-year-old child. Forensic Sci Int 2010;198:19–22. [7] Karakoc F, Karadag B, Akbenlioglu C, et al. Foreign body aspiration: what is the outcome? Pediatr Pulmonol 2002;34:30–36. [8] Holinger LD, Poznanovic SA. Foreign bodies of the airway and esophagus. In: Flint PW, Haughey, Lung VJ, Niparko JK, Richardson MA, Robbins KT, Thoms JR, editors. Cummings otolaryngology Head and Neck Surgery, vol. 1. Philadelphia: Mosby; 2010. p. 2935–2943. [9] Maihiasen RA, Cruz RM. Asymptomatic. Near-total Airway Obstruction by a cylindrical tracheal foreign body. Laryngoscope 2005;115(2):274–277. [10] Bhat VS, Al-Saadi KA, Bessiouni IE, Tuffaha AS. Embedded esophageal foreign body. A diagnostic challenge. Saudi Med J 2009;30:433–435.
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Please cite this article in press as: Swain SK, et al. Button battery aspiration in children: Our experiences in a tertiary care teaching hospital of eastern India. Pediatr Pol. (2017), http://dx.doi.org/10.1016/j.pepo.2017.03.012
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[11] Tander B, Yazici M, Rizalar R, Ariturk E, Ayyildiz SH, Bernay F. Coin ingestion in children: which size is more risky? J Laparoendosc Adv Surg Tech 2009;19:241–243. [12] Bronstein AC, Spyker DA, Cantilena Jr LR, Green JL, Rumack BH, Heard SE. American Association of Poison Control Centers. 2007 Annual Report of the American Association of
Poison Control Centers’ National Poison Data System (NPDS): 25th Annual Report. Clin Toxicol (Phila) 2008;46 (10):927–1057. [13] Hasdiraz L, Oguzkaya F, Bilgin M, Bicer C. Complications of bronchoscopy for foreign body removal: experience in 1,035 cases. Ann Saudi Med 2006;26:283–287.
Please cite this article in press as: Swain SK, et al. Button battery aspiration in children: Our experiences in a tertiary care teaching hospital of eastern India. Pediatr Pol. (2017), http://dx.doi.org/10.1016/j.pepo.2017.03.012
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Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/pepo 1
Original research article/ Artykuł oryginalny
2
Button battery aspiration in children: Our experiences in a tertiary care teaching hospital of eastern India
3 4 5
6 7 8 9 10 11
Q1
Santosh Kumar Swain 1,*, Shaswat Kumar Pattnaik 2, Alok Das 1, Mahesh Chandra Sahu 3 1
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, India 2 Department of Anesthesiology, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, India 3 Directorate of Medical Research, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, India
article info
abstract
Article history:
Background: Aspiration of button battery is in children is increasing in recent years due
Received: 11.02.2017
to more accessibility of electronic toys to the children. The electrochemical composition of
Accepted: 21.03.2017
button battery may cause extensive damage. It should be promptly and immediately
Available online: xxx
removed otherwise it leads to complications and death. Objective: To study the clinical
Keywords: Foreign body bronchus
design: A retrospective study. Methods: Six children those aspirated button battery and from the tracheobronchial tree during December 2012 to January 2017. Results: Button
button battery rigid bronchoscopy
matic after aspiration. One child came with stridor. The time interval between battery
presentations and outcome of the button battery aspiration among the children. Study underwent rigid bronchoscopy with spontaneous ventilation and followed by removal battery aspiration is common among male child in our study. All children were symptoaspiration and attending hospital was 25.33 h. Out of six patients two shows button battery in left bronchus, three in right bronchus and one is near the carina. Average hospital stay was 3.16 days. Conclusion: Early detection of such foreign bodies is essential to safe removal. Management approach has to be systematic. Preoperative history taking, radiological assessment followed by rapid intervention by skilled bronchoscopist usually results in favorable outcome. © 2017 Polish Pediatric Society. Published by Elsevier Sp. z o.o. All rights reserved.
12 13 14
Introduction
15
Aspiration of foreign body (FB) is a leading cause of death among children in the age group of 1–3 years [1]. Often death
occurs due to FB aspiration at the time of inhalation, but those reach the hospital and alive are less in number. Button battery ingestion is relatively rare occurrence and increasing in now days due to more accessibility of electronic toys to the children. One also except more incidence of button
* Corresponding author at: Department of Otorhinolaryngology, IMS & SUM Hospital, Kalinga Nagar, Bhubaneswar 751003, Odisha, India. Tel.: +91 9556524887. E-mail address: [email protected] (S.K. Swain). http://dx.doi.org/10.1016/j.pepo.2017.03.012 0031-3939/© 2017 Polish Pediatric Society. Published by Elsevier Sp. z o.o. All rights reserved.
Please cite this article in press as: Swain SK, et al. Button battery aspiration in children: Our experiences in a tertiary care teaching hospital of eastern India. Pediatr Pol. (2017), http://dx.doi.org/10.1016/j.pepo.2017.03.012
16 17 18 19 20
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battery aspiration, however few such reports have been reported [2]. This may be due several causes. Most of the aspirated FBs are food items whereas the batteries are unpleasant taste sensation which is usually expectorated or swallowed immediately. Children accesses to button batteries are often technically difficult as these are usually housed in devices which act as barriers. The rarity of FB aspiration is also due to the protection of airways with epiglottis, arytenoids and cough reflex. FB aspirations to the tracheobronchial tree are rare and fatal occurrences, more common among pediatric age group in emergency rooms. The common sites of FB impaction in tracheobronchial tree in order are right bronchus, left bronchus and trachea [3]. The smooth and shiny appearance of button battery often attractive to the children and they eagerly pick and handle them [4]. Button battery FBs are always have fatal outcome to the human being due to their chemical composition [5, 6]. FB aspiration is a fatal accident in children, especially during 3– 4 years age group and is a common etiology of morbidity and mortality [7]. The button batteries are commonly used in hearing aid, watches, toys or games and calculators. After lodgment of button batteries, lead to rapid tissue damage. Early detection of button batteries in airways is the key behind the protection of fatal outcome. Our study aims to describe the experiences of the clinical presentations, management and outcome of the button battery aspiration among the children in a tertiary care teaching hospital.
48
Materials and methods
49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68
This is a retrospective study where six children with aspiration of button batteries attended the Department of Otorhinolaryngology in a tertiary care teaching hospital of eastern India during period of December 2012 to January 2017. The age, sex and presenting clinical features of the patient as well as imaging localization of the button batteries, interval between aspiration and clinical course followed by treatment were analyzed retrospectively. All patients were managed by rigid bronchoscopy. The composition, discharge state and type of the battery were not known for all aspirated children. Four patients were male child and two were female. Age ranged from 1 year to 6 years. Institutional ethical committee approved our study. A thorough history was taken with accidental inhalation of battery into the airways along with clinical symptoms like cough, chocking sensation and breathing difficulty. Proper head and neck examination along with appropriate radiological evaluation were done for the diagnosis of button battery in the tracheobronchial airways. The button batteries were removed on the emergency basis under general anesthesia. Brief clinical profiles of the six patients are given below.
69
Case 1
70 71 72 73
A 13-month-old female baby brought to the emergency department after 6 hours of sudden onset of dyspnea and cough. Parents of baby were not able to provide any source of FB ingestion. A chest radiograph showed a metallic FB in the lower airway. CT scan of the thorax confirmed a disc shaped
Fig. 1 – CT scan of the thorax showing button battery in the left bronchus
metallic FB at the lower part of the left bronchus (Fig. 1). Patient was immediately shifted to operation theater and underwent rigid bronchoscopy under general anesthesia with 2.5 mm size in diameter. The FB (Fig. 2) was removed without any complications with the help of telescopic optical bronchial FB forceps. The postoperative period of the child was uneventful. The chest X-ray was done on second day and found to be normal. The child was discharged after 72 hours.
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Case 2
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A 4-year-old boy was seen in the emergency department with history of button battery ingestion 24 hours before presentation. After ingestion, he was presenting with cough and shortness of breath. Chest X-ray confirmed the metallic disc shaped FB in the right bronchus. The patient was urgently shifted to the operation theater for removal of FB. He underwent rigid bronchoscopy with spontaneous ventilation via attached port of rigid bronchoscope. The button battery was removed. There was necrosis of the mucosa of the bronchus due to button battery (Fig. 3a and b), may be due to rapid release of chemicals from the battery. Postoperatively patient developed bronchospasm and managed with steroid nebulisation and steroid injection. He recovered and shifted to pediatric intensive care unit for observation. He was discharged after 5 days of hospital stay.
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Fig. 2 – Button battery after recovery from the bronchus
Fig. 4 – Chest X-ray showing radiopaque foreign body with characteristic halo sign which is typical of a button battery
Fig. 3 – Endoscopic picture showing necrosis of the mucosa of bronchus (a) and button battery (b) after its removal
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Case 3
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A 19-month-old male child presented with history of swallowing a button battery since one day. The child was presenting with cough and breathing difficulty after swallowing of battery. X-ray chest revealed a disc shaped metallic FB in the right bronchus and its location again confirmed by CT scan of thorax. Immediately patient shifted to the operation room and rigid bronchoscopy was done under general anesthesia. Battery was removed from the right bronchus by telescopic optical bronchial FB forcep. Postoperative recovery of the patient was uneventful and discharged after 48 hours.
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Case 4
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A 3-year-old girl child referred to out patient Department of Otorhinolaryngology for sudden onset of cough and dyspnea with complaints of aspiration of FB. There was history of
accidental inhalation of a battery from hearing aid. Patient came after 72 hours of aspiration of FB. On clinical examination, child was presenting breathlessness, stridor and coughing. On chest auscultation, there was reduced air entry into the left lungs. On examination, nose, ear, oral cavity, oropharynx and neck are within normal limit. Immediately X-ray of the neck and chest were done, showed a radioopaque foreign body at the lower trachea (Fig. 4) which was confirmed by CT scan of the thorax. Since the child was dyspneic and with stridor, bronchodilators started and he was immediately taken to operation theater for rigid bronchoscopy under general anesthesia. The FB was successfully removed out by rigid ventilating bronchoscopy and optical forcep from the trachea near the carina without any complications. The patient was given antibiotics and nebulisation with bronchodilators. The child was discharged after 48 hours.
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Case 5
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A 5-year-old boy aspirated a button battery leading to immediate breathing difficulty, restless and presenting cough. Two hours later, he came to emergency department of our hospital. A chest X-ray was done showing a metallic FB in the lower airway. CT scan of thorax confirmed it in the right bronchus and was also showing collapse of the right lobe of lungs. His oxygen saturation dropped to 60– 70%. Immediately he was shifted to operation room. Rigid bronchoscope size 4.5 mm, length 30 cm with attached port for spontaneous ventilation was used for bronchoscopy
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Fig. 5 – CT scan of the thorax showing a radio-opaque foreign body (button battery) in the left bronchus
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procedure. Rigid bronchoscope showed a button battery completely blocking right bronchus, which was again confirmed by optical forceps. After two to three trials, FB was removed by grasp forceps. The patient discharged after 72 hours.
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Case 6
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A 20-month-old female baby was admitted to the department of Otorhinolaryngology for acute onset of dyspnea and cough. There was history of button battery aspiration one day back. The baby was afebrile and conscious. Baby had tachypnea with respiratory rate 52/minute and pulse oximetry showing oxygen saturation of 94% in air. Air entry was reduced in left side of chest on auscultation but there was no cyanosis. Chest X-ray was showing a small circular metallic FB in the left bronchus. The exact location and FB
was again confirmed from the CT scan of the thorax (Fig. 5). Immediately planned for rigid bronchoscopy and shifted to the operation room. In the first attempt of surgeon, the foreign body could not located and oxygen saturation fell down to 60%. Second attempt was made after making oxygen saturation to 100% and button battery was seen in lower part of the left bronchus and removed with the help of grasping forcep. After foreign body removal, air entry into left side of chest was started. The patient was discharged after 4 days.
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Anesthesia
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The objective of the anesthesia during bronchoscopy period is always maintaining spontaneous respiration throughout the procedure. All patients were pre-oxygenated with 100% oxygen for 5 min. The premedication used are injection glycopyrrolate (10 mg/kg IV), injection midazolam (0.04 mg/kg IV), injection fentanyl (1 mg/kg IV). Then the patient was sedated with propofol injection (2 mg/kg) and bag mask ventilation. The laryngoscopy was done and the trachea was sprayed with 1% lidocaine. Succinyl choline injection was given and once the patient was fully paralyzed, handed over to the surgeon for rigid bronchoscopy. The anesthesia circuit is connected to the side port of the rigid bronchoscope for ventilation. Sevoflurane was also used for maintenance via side port of the bronchoscope along with 100% oxygen. After successful rigid bronchoscopy procedure, the child were administered with 100% oxygen by mask and simultaneously nebulized with 1:10 000 adrenaline till complete awake of the child.
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Results
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Out of the 6 children, there were 4 boys and 2 girls in our study. The patient age ranged from 13 months to 5 years and the mean time from foreign body aspiration to treatment was 25.33 hours (2 to 72 hours). Postoperative recovery of children was uneventful except one case and X-ray chest done for assessing the proper expansion of the lungs. The right bronchus, left bronchus and trachea were the common sites for lodgment of button battery. Post-bronchoscopy complications occurred in one patient (Case 2) and that was bronchospasm. It was treated conservatively. There were no death occurred in our series. Detail clinical profiles of the patients are given in Tables I and II. Characteristics of button batteries and its injuries are given in Table III.
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Table I – Clinical profile and outcome of patients Patients 1 2 3 4 5 6
Age
Sex
Location
Removal interval
Hospital stay
Outcome
13 months 4 years 19 months 3 years 5 years 19 months
Female Male Male Female Male Male
Left bronchus Right bronchus Right bronchus Lower trachea Right bronchus Left bronchus
6 hours 24 hours 24 hours 72 hours 2 hours 24 hours
72 hours 5 days 48 hours 48 hours 72 hours 4 days
Successful Bronchospasm Successful Successful Successful Successful
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in hearing aids, calculators, watches, cameras, glucometers, toys and many electronic instruments. These batteries are sealed and contain corrosive and toxic chemicals and heavy metals like mercury, silver, zinc, nickel, chromium, cadmium, lithium and manganese along with a concentrated alkaline electrolyte solution of 26% to 45% potassium or sodium hydroxide [10, 11]. These chemicals starts leaking if kept in contact with wet mucosal surface like mouth, esophagus or trachea. Prolonged contact with mucosa cause extensive damage. Detail electrochemical properties of button batteries are given in Table IV. The American Association of Poison Control Centers documented 476 cases of button or disc battery exposure to human being as foreign body where 59% had no morbidity, 9% had moderate to major morbidity without any death report in 2007[12]. Button batteries in gastrointestinal tract may pass without much complication although it depends on the size of the battery. The button battery in the tracheobronchial airways lodges and leads to devastating complications by rapid tissue destruction. The chemical composition of the disc batteries is alkaline corrosive materials or heavy metals. On the basis of the chemical composition, the disc batteries are classified into four types: mercury (consists of mercuric oxide and aqueous potassium hydroxide), manganese (consists of manganese dioxide and aqueous potassium hydroxide) and lithium manganese (consists of lithium and manganese dioxide). Lithium containing batteries are more dangerous and have the highest potential to cause extensive mucosal damage whereas the zinc containing batteries are least dangerous. The complications due to button or disc batteries aspiration or ingestion occur due to four types of mechanisms. These are leakage of alkali causing direct caustic injury of the tissue, absorption of toxic materials, electric discharge causing mucosal burns and pressure necrosis of the mucosa. One of our cases (case.2) was showing necrosis of the bronchial mucosa which may be
Table II – Clinical presentations and chest findings among six patients Clinical Presentation
Number of patients
Cough Wheezing Dyspnea Decreased air entry into lungs Abnormal pulmonary sounds Stridor
5 4 3 5 4 1
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Discussion
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Incidence of airway FBs is more common among children than adult. Often children explore their world by taking any objects into their mouth. The children have habit of putting objects in the mouth and assess the taste and texture. Often small children are taken care by elder siblings in village area. Negligence, illiteracy, mental infirmity, talking while eating, alcohol intoxication and wearing dental prosthesis are some important causes for FB aspiration. There are three phases of clinical presentation after FB aspiration. First phase of FB aspiration consists of gagging, chocking and coughing at the time of aspiration. Parents of the children will give history of this phase of clinical presentation if witnessed. The cough is a protective mechanism, gradually fatigued and ensures the second phase for few hours. Complications usually occur in the third phase when definite obstruction occurs or erosion or infections are associated [8, 9]. If FB stay for longer period, it results in granulation tissue, narrowing of airway and symptoms are aggravated [9]. Due to increase use of miniaturized electronic toys and equipments, the incidence of small size batteries aspiration appears to be increased. The button batteries are tiny disc shaped power units commonly used
Table III – Characteristics of button batteries aspirated by children Patients 1 2 3 4 5 6
Size of button battery (mm)
Type of battery
Surrounding tissue damage bay battery
10 12 15 20 12 15
Alkaline Alkaline Alkaline Alkaline Alkaline Alkaline
Mucosal burn Necrosis of surrounding tissue Mucosal burn Mucosal burn Mucosal burn and necrosis of adjacent tissue Mucosal burn
Table IV – Electrochemical properties of commonly available batteries Types of battery
Active chemical compound
Voltage (V)
Toxicity
Disposable
Zinc carbon Zinc manganese dioxide Lithium Mercury oxide Zinc air
1.5 1.5 1.5 1.35 1.35–1.65
Zinc causes corrosive reaction Alkali leak causes severe burn Cause severe caustic reaction
Nickel zinc Nickel cadmium Nickel metal-hydride Lithium-ions
1.6 1.2 1.2 3.6
Rechargeable
Commonly used battery Commonly used in hearing aid
Presently available in market
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due to rapid release of alkaline materials from the battery. All our patients had a positive history of FB aspiration with presentation of coughing and chocking sensation. As airway FBs pose a life-threatening risk, especially in children, should be removed early without delay. Rigid bronchoscopy has several advantages for removal FB from airway. The advantages are better ability to ventilate the patient and also visualize and manipulation of the FB. The younger the patient, the greater the advantages of the rigid bronchoscopy. Delay in diagnosis of button battery in airway can lead to disastrous outcomes. All of our cases were not in such long-term squeal. Parents and the community at large should be educated properly regarding the risk of button batteries aspiration in children. FB like Button battery should be removed without delay only in a hospital well equipped with instruments and expert surgeon, anesthetists and medical staff experienced with bronchoscopy. Complications of repeated rigid bronchoscopy include laryngeal trauma, bleeding, laryngeal edema, laryngospasm, bronchospasm, tracheobronchial laceration, hypoxemia and pneumothorax [13]. Button battery aspiration is an emerging killer among pediatric patients worldwide. As the prompt surgical intervention is not always available to all patients, so in delayed cases button battery aspiration create a devastating outcome. It is always better to give preventive efforts for raising awareness among parents and public. There should be always warning labels apply to the batteries and electronic instruments along with instructions for treatment. Battery manufacturing company should educate the public regarding the potential hazard for button battery ingestion or aspiration. Battery manufacturing company should also urge to give more secured fastened and child resistant battery compartment.
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Conclusion
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The incidence of Button or disc battery ingestion is rising due to increase use of portable miniaturized electronic toys among children. Aspiration of button battery is a serious condition which is best treated by urgent rigid bronchoscopy. This type of FB aspiration in children could be prevented by parent education and public awareness. Although the button battery aspiration is rare incidence, pediatrician or physician who treat these children should be aware of the possible fatal and serious outcomes and facilitate the prompt intervention. In battery production industry, improved packaging and button battery markings will help to minimize morbidity among children.
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Study limitation
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This study has a relatively small sample size. However, the detail clinical presentations and management of the button battery aspiration will definitely give a management strategy and it's awareness among pediatrician, otolaryngologists, parents and public.
Authors’ contributions/ Wkład autorów
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According to order.
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Conflict of interest/ Konflikt interesu
313
None declared.
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Financial support/ Finansowanie
315
None declared.
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Ethics/ Etyka
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The work described in this article has been carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) for experiments involving humans; EU Directive 2010/63/EU for animal experiments; Uniform Requirements for manuscripts submitted to Biomedical journals.
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references/ pi smiennictwo
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[11] Tander B, Yazici M, Rizalar R, Ariturk E, Ayyildiz SH, Bernay F. Coin ingestion in children: which size is more risky? J Laparoendosc Adv Surg Tech 2009;19:241–243. [12] Bronstein AC, Spyker DA, Cantilena Jr LR, Green JL, Rumack BH, Heard SE. American Association of Poison Control Centers. 2007 Annual Report of the American Association of
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