- Email: [email protected]
Double button battery ingestion – The “macaroon” sign
Accepted Manuscript Double button battery ingestion – The “macaroon” sign Emma Littlehales, Eric Levi, Nikki Mills, Russell Metcalfe, James Hamill PII:
S2213-5766(18)30142-8
DOI:
10.1016/j.epsc.2018.06.013
Reference:
EPSC 1024
To appear in:
Journal of Pediatric Surgery Case Reports
Received Date: 8 June 2018 Revised Date:
21 June 2018
Accepted Date: 23 June 2018
Please cite this article as: Littlehales E, Levi E, Mills N, Metcalfe R, Hamill J, Double button battery ingestion – The “macaroon” sign, Journal of Pediatric Surgery Case Reports (2018), doi: 10.1016/ j.epsc.2018.06.013. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Double button battery ingestion – the “macaroon” sign Authors: Emma Littlehales BMedSci BMBS a, Eric Levi FRACS MBBS MPH&TM b, Nikki Mills BHB, MBChB, FRACS, Dip Paeds b, Russell Metcalfe FRANZCR c, James Hamill PhD, FACS, FRACS a
RI PT
Institution: a) Department of Paediatric Surgery, Starship Child Health, Auckland b) Department of Paediatric Otorhinolaryngology, Starship Child Health, Auckland c) Department of Paediatric Radiology, Starship Child Health, Auckland
SC
Corresponding Author: Emma Littlehales, Department of Paediatric Surgery, Starship Children's Hospital, 2 Park Rd, Grafton, Auckland 1023, New Zealand [email protected]
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Keywords: Button battery, caustic ingestion, esophageal injury, foreign body ingestion, electrical injury, acetic acid
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This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declarations of interest: none
ACCEPTED MANUSCRIPT
ABSTRACT
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Button (Disc) battery impaction in the esophagus is a time critical presentation with significant associated morbidity and mortality. We present the case of a 15-month old boy with an unwitnessed foreign body ingestion, and who was subsequently found to have two ingested lithium button batteries, which were lodged at the upper esophagus, distal to cricopharyngeus. We discuss the “macaroon sign” of two button batteries lying parallel to one another, with both positive poles facing each other, as this may be an unusual barrier to urgent identification of the impacted foreign body as batteries.
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0.25% acetic acid was used as a neutralising agent at the time of button battery removal (8 hours after ingestion), based on published evidence that this effectively decreases tissue pH and mitigates the severity of the injury in animal models, whilst not increasing ambient tissue temperature as once thought[4]. Our patient had a significantly better clinical outcome than predicted from the severity of the burn at time of button battery removal, suggesting acetic acid used topically is a safe adjunct treatment of impacted ingested button batteries and may reduce the likelihood of serious long term sequelae.
CASE
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A 15 month old boy presented to the Children’s Emergency Department with a history of possible unwitnessed foreign body ingestion. His parents gave a history of a sudden choking episode at approximately 2pm that afternoon while the child was on his own. He was found to be distressed and coughing, was administered first aid by his parent in the form of back blows, causing him to vomit. He then proceeded to have several further episodes of vomiting when given food and drink throughout the afternoon, and was noted to be drooling at times.
EP
On presentation to the Children’s Emergency Department, 7 hours following ingestion, he was drooling but had no airway compromise. Neck radiographs demonstrated a foreign body in the esophagus, although the diagnosis of button (disc) battery was not immediately recognized because of the atypical profile of the foreign body on the lateral film [Figure 1, 2].
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The child was then taken immediately to the operating theatre, intubated, and with a rigid esophagoscope and optical grasping forceps, the surgeon removed two button batteries from the upper esophagus just beyond cricopharyngeus. The esophagus was further examined and severe circumferential erosion of the upper esophageal mucosa with marked mucosal oedema above and below the area of necrosis [Figure 3]. There was no obvious esphageal perforation. The foreign bodies were both 20mm lithium/manganese dioxide 3V button batteries found with the positive poles facing each other [3] [Figure 4]. The estimated time from ingestion to removal was 8 hours. A rigid bronchoscopy was then performed to assess the airway, showing erythematous trachealis muscle in the upper third of the trachea but no erosion. Once the patient was re-intubated again with a cuffed endotracheal tube, a rigid esophagoscope with a suction channel was passed into the upper esophagus. The esophagus was lavaged with 100mls of 0.25% acetic acid via the suction channel. At completion of the procedure a nasogastric feeding tube was gently passed into the stomach under endoscopic vision. The child made an uneventful recovery. He was made nil by mouth for a week and was given a course of post operative antibiotics for post operative fevers. There was no clinical evidence of
ACCEPTED MANUSCRIPT
esophageal perforation. A contrast study on day 7 post ingestion demonstrated contrast passing freely through the esophagus and into the stomach with no esophageal leak or stenosis identified [Figure 5]. He was commenced on full oral diet, which he tolerated well, and was discharged at day 9 post injury. On review at 6 weeks post injury, he was tolerating a soft diet well, but was having some mild dysphagia with solids, and will be further assessed with an oral contrast study at 3 months post injury. DISCUSSION
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This case highlights several key points in the diagnosis and management of button battery ingestion. Foreign body ingestion is relatively common [2, 3] and 70 – 80% of cases of foreign body in the upper GI tract are seen in children under 15, of which the highest incidence is seen in children between 1 and 3. The most common site of impaction in children is the upper esophageal sphincter [1, 2, 7]. Significant complications can arise when a button battery becomes impacted in the esophagus, however those that pass through the GI tract without becoming impacted usually do so without incident [1]. Those that do become lodged become a time critical emergency, as complications can occur in as little as two hours. Potentially fatal complications (including tracheoesophageal and aorto-esophageal fistula) have been reported and can present in a delayed fashion, up to 18 days post removal [5]. The most common long term complication is esophageal stenosis created from the circumferential luminal injury, often requiring serial dilatations and in severe cases excision of the scarred segment of esophagus. Other less common but severe complications include recurrent laryngeal nerve injuries, salivary leak into the neck and mediastinitis. For these reasons, emergent endoscopic removal is the recommended treatment of an impacted button battery [1, 3, 5, 7], and early identification of these patients is paramount.
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The characteristic X ray imaging of a button battery in the upper esophagus is of a well defined densely radio-opaque cylindrical object with a double ring in an AP view, and a bilaminar appearance in a lateral view. This is important to differentiate them from a coin, which has a more uniform structure and only a single ring [2, 3]. In this case, the double ring can be easily seen on the AP [Figure 1], but the characteristic lateral appearance is not present, due to the presence of two batteries lying next to each other [Figure 2]. This unusual appearance led to some initial uncertainty as to the nature of the foreign body that had been ingested. In addition, the importance of the lateral view highlighting two foreign bodies is noted, as it is possible to miss a second object after the first had been removed, especially in the context of oedema or bleeding which can make the esophagoscopy technically difficult. In addition, the lateral is key in localising the foreign body to the esophagus, distinguishing it from inhaled foreign bodies located in the trachea. It also help to assess tracheal narrowing from inflammation, and to assess for the bilaminar “step off” sign in the case of a battery, which may be easier to identify than the double ring sign seen on the AP. The key mechanism of injury in the esophagus is due to electrical injury. Mucosal contact on both sides of a battery create a flow of electrical current, causing generation of sodium hydroxide in tissues and leading to local hydrolysis and liquefactive tissue injury with a significant increase in pH of the surrounding tissue [3-6]. It is also thought that the alkalotic liquefactive injury continues to occur hours after the battery has been removed [6]. In this case, as can be seen in the lateral view, the two positive poles are touching each other, with the two negative poles being in contact with the esophageal mucosa, leading to an image with the macaroon shape described, with a wider middle section, a small line of separation between the two batteries, and a smaller diameter at the outside edge [Figure 2].
ACCEPTED MANUSCRIPT The largest study into button battery ingestion found that the most important predictors of significant complications include battery diameter of >20mm, age <4 years and ingestion of >1 battery, all present in this case [5]. 12.6% of all patients under 6 who ingest a button battery of >20mm diameter will experience a serious complication. It was also noted that clinicians missed the diagnosis of button battery ingestion in 27% of cases, and 92% of fatal presentations were unwitnessed, most in non-verbal children. It has also been found that outcomes are worsening, likely due to the increasing use of the 20mm lithium ion batteries in modern households. [5,7]
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RI PT
A novel aspect of this case has been the use of acetic acid to lavage the esophagus post removal of the batteries to mitigate the severity of the burn. A recent paper by Jatana et al [4] has looked into the mechanism and treatment of the esophageal injury left following the removal of a button battery. A concern with using neutralising agents has been a suggestion that this may raise the tissue temperature of the area and cause a thermal injury in the reaction. Using animal models, no significant change in temperature of esophageal tissue was seen with instillation of 0.25% acetic acid, and the pH of tissues was seen to decrease from a highly alkaline 11-12, down to a more neutral pH of 6, as well as reducing visible eschar.
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The most important factor in treating esophageal button batteries is time to diagnosis and extraction. The injury free window in which a button battery can be removed with no minimal complications is <2 hours [5, 6], and increasing severity is seen with increasing time of contact [3, 5]. In an animal model, perforation was seen in every case of a battery being in place for over 12 hours [6]. This case demonstrates the importance of a high index of suspicion for unwitnessed ingested foreign bodies in a young child who presents with choking and vomiting. The associated imaging should help guide treating physicians towards a correct diagnosis. An important adjunct treatment method with 0.25% acetic acid lavage to neutralise the mucosal alkalotic injury has been demonstrated in this case to be safe and potentially effective in reducing local and long term complications. This has significant implications for treatment of ingested, inhaled or nasal impacted button batteries.
EP
Patient consent: Formal written consent was obtained from the child’s parents to publish this case report, including consent for publication of all imaging studies and intraoperative photographs and videos.
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Funding: No funding or grant support. Authorship: All authors attest that they meet the current ICMJE criteria for Authorship. Conflict of interest: The following authors have no financial disclosures: EL, EL, NM, RM, JH REFERENCES 1. Munoz, JC. Foreign Body Ingestion. BMJ Best Practice. 2017. 2. Pugmire, BS, Lim, R and Avery, LL. Review of ingested and aspirated foreign bodies in children and their clinical significance for radiologists. Radiographics. 2015; 35(5), 1528-38. 3. Sinclair K and Hill ID. Button and cylindrical battery ingestion: Clinical features, diagnosis and initial management. UpToDate. 2017
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4. Jatana, KR, Rhoades, K, Milkovich, S and Jacobs, IN. Basic mechanism of button battery ingestion injuries and novel mitigation strategies after diagnosis and removal. The Laryngoscope. 2017; 127(6), 1276-82. 5. Litovitz, T, Whitaker, N, Clark, L, White, NC and Marsolek, M. Emerging battery-ingestion hazard: clinical implications. Pediatrics. 2010; 125(6), 1168-77. 6. Völker, J, Völker, C, Schendzielorz, P, Schraven, SP, Radeloff, A, Mlynski, R, Hagen, R and Rak, K. Pathophysiology of esophageal impairment due to button battery ingestion. International journal of pediatric otorhinolaryngology. 2017; 100, 77-85. 7. Litovitz, T, Whitaker, N and Clark, L. Preventing battery ingestions: an analysis of 8648 cases. Pediatrics. 2010; 125(6), 1178-83.
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Figure 1: AP view of a neck and chest, demonstrating an impacted button battery lodged at the cervical thoracic junction at the level of medial clavicles.
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Figure 2: Lateral view of neck and thoracic inlet, demonstrating the “macaroon sign” of two parallel button batteries
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Figure 3: Rigid oesophagoscopy following removal of both button batteries demonstrating circumferential esophageal burns, pre and post irrigation with acetic acid. Still image from video
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Figure 4: The batteries retrieved from the patient. Corrosion can be seen on the surface of both, along with the identifying marks.
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Figure 5: Contrast study at day 7 post ingestion, showing no contrast leakage or stenosis
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Highlights
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Button battery ingestion causes significant morbidity and mortality in children, and an impacted button battery is a time critical emergency The most important predictors of significant complications include battery diameter of >20mm, age <4 years and ingestion of >1 battery Identification on x-ray is key and the cardinal signs on imaging include a double ring in an AP view, and a bilaminar appearance in a lateral view A novel form of treatment is irrigation with acetic acid which has shown promise in animal studies and which was used in this case to good effect
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ACCEPTED MANUSCRIPT
Double button battery ingestion – the “macaroon” sign
AC C
EP
TE D
M AN U
SC
RI PT
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declarations of interest: none
S2213-5766(18)30142-8
DOI:
10.1016/j.epsc.2018.06.013
Reference:
EPSC 1024
To appear in:
Journal of Pediatric Surgery Case Reports
Received Date: 8 June 2018 Revised Date:
21 June 2018
Accepted Date: 23 June 2018
Please cite this article as: Littlehales E, Levi E, Mills N, Metcalfe R, Hamill J, Double button battery ingestion – The “macaroon” sign, Journal of Pediatric Surgery Case Reports (2018), doi: 10.1016/ j.epsc.2018.06.013. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Double button battery ingestion – the “macaroon” sign Authors: Emma Littlehales BMedSci BMBS a, Eric Levi FRACS MBBS MPH&TM b, Nikki Mills BHB, MBChB, FRACS, Dip Paeds b, Russell Metcalfe FRANZCR c, James Hamill PhD, FACS, FRACS a
RI PT
Institution: a) Department of Paediatric Surgery, Starship Child Health, Auckland b) Department of Paediatric Otorhinolaryngology, Starship Child Health, Auckland c) Department of Paediatric Radiology, Starship Child Health, Auckland
SC
Corresponding Author: Emma Littlehales, Department of Paediatric Surgery, Starship Children's Hospital, 2 Park Rd, Grafton, Auckland 1023, New Zealand [email protected]
M AN U
Keywords: Button battery, caustic ingestion, esophageal injury, foreign body ingestion, electrical injury, acetic acid
AC C
EP
TE D
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declarations of interest: none
ACCEPTED MANUSCRIPT
ABSTRACT
RI PT
Button (Disc) battery impaction in the esophagus is a time critical presentation with significant associated morbidity and mortality. We present the case of a 15-month old boy with an unwitnessed foreign body ingestion, and who was subsequently found to have two ingested lithium button batteries, which were lodged at the upper esophagus, distal to cricopharyngeus. We discuss the “macaroon sign” of two button batteries lying parallel to one another, with both positive poles facing each other, as this may be an unusual barrier to urgent identification of the impacted foreign body as batteries.
M AN U
SC
0.25% acetic acid was used as a neutralising agent at the time of button battery removal (8 hours after ingestion), based on published evidence that this effectively decreases tissue pH and mitigates the severity of the injury in animal models, whilst not increasing ambient tissue temperature as once thought[4]. Our patient had a significantly better clinical outcome than predicted from the severity of the burn at time of button battery removal, suggesting acetic acid used topically is a safe adjunct treatment of impacted ingested button batteries and may reduce the likelihood of serious long term sequelae.
CASE
TE D
A 15 month old boy presented to the Children’s Emergency Department with a history of possible unwitnessed foreign body ingestion. His parents gave a history of a sudden choking episode at approximately 2pm that afternoon while the child was on his own. He was found to be distressed and coughing, was administered first aid by his parent in the form of back blows, causing him to vomit. He then proceeded to have several further episodes of vomiting when given food and drink throughout the afternoon, and was noted to be drooling at times.
EP
On presentation to the Children’s Emergency Department, 7 hours following ingestion, he was drooling but had no airway compromise. Neck radiographs demonstrated a foreign body in the esophagus, although the diagnosis of button (disc) battery was not immediately recognized because of the atypical profile of the foreign body on the lateral film [Figure 1, 2].
AC C
The child was then taken immediately to the operating theatre, intubated, and with a rigid esophagoscope and optical grasping forceps, the surgeon removed two button batteries from the upper esophagus just beyond cricopharyngeus. The esophagus was further examined and severe circumferential erosion of the upper esophageal mucosa with marked mucosal oedema above and below the area of necrosis [Figure 3]. There was no obvious esphageal perforation. The foreign bodies were both 20mm lithium/manganese dioxide 3V button batteries found with the positive poles facing each other [3] [Figure 4]. The estimated time from ingestion to removal was 8 hours. A rigid bronchoscopy was then performed to assess the airway, showing erythematous trachealis muscle in the upper third of the trachea but no erosion. Once the patient was re-intubated again with a cuffed endotracheal tube, a rigid esophagoscope with a suction channel was passed into the upper esophagus. The esophagus was lavaged with 100mls of 0.25% acetic acid via the suction channel. At completion of the procedure a nasogastric feeding tube was gently passed into the stomach under endoscopic vision. The child made an uneventful recovery. He was made nil by mouth for a week and was given a course of post operative antibiotics for post operative fevers. There was no clinical evidence of
ACCEPTED MANUSCRIPT
esophageal perforation. A contrast study on day 7 post ingestion demonstrated contrast passing freely through the esophagus and into the stomach with no esophageal leak or stenosis identified [Figure 5]. He was commenced on full oral diet, which he tolerated well, and was discharged at day 9 post injury. On review at 6 weeks post injury, he was tolerating a soft diet well, but was having some mild dysphagia with solids, and will be further assessed with an oral contrast study at 3 months post injury. DISCUSSION
M AN U
SC
RI PT
This case highlights several key points in the diagnosis and management of button battery ingestion. Foreign body ingestion is relatively common [2, 3] and 70 – 80% of cases of foreign body in the upper GI tract are seen in children under 15, of which the highest incidence is seen in children between 1 and 3. The most common site of impaction in children is the upper esophageal sphincter [1, 2, 7]. Significant complications can arise when a button battery becomes impacted in the esophagus, however those that pass through the GI tract without becoming impacted usually do so without incident [1]. Those that do become lodged become a time critical emergency, as complications can occur in as little as two hours. Potentially fatal complications (including tracheoesophageal and aorto-esophageal fistula) have been reported and can present in a delayed fashion, up to 18 days post removal [5]. The most common long term complication is esophageal stenosis created from the circumferential luminal injury, often requiring serial dilatations and in severe cases excision of the scarred segment of esophagus. Other less common but severe complications include recurrent laryngeal nerve injuries, salivary leak into the neck and mediastinitis. For these reasons, emergent endoscopic removal is the recommended treatment of an impacted button battery [1, 3, 5, 7], and early identification of these patients is paramount.
AC C
EP
TE D
The characteristic X ray imaging of a button battery in the upper esophagus is of a well defined densely radio-opaque cylindrical object with a double ring in an AP view, and a bilaminar appearance in a lateral view. This is important to differentiate them from a coin, which has a more uniform structure and only a single ring [2, 3]. In this case, the double ring can be easily seen on the AP [Figure 1], but the characteristic lateral appearance is not present, due to the presence of two batteries lying next to each other [Figure 2]. This unusual appearance led to some initial uncertainty as to the nature of the foreign body that had been ingested. In addition, the importance of the lateral view highlighting two foreign bodies is noted, as it is possible to miss a second object after the first had been removed, especially in the context of oedema or bleeding which can make the esophagoscopy technically difficult. In addition, the lateral is key in localising the foreign body to the esophagus, distinguishing it from inhaled foreign bodies located in the trachea. It also help to assess tracheal narrowing from inflammation, and to assess for the bilaminar “step off” sign in the case of a battery, which may be easier to identify than the double ring sign seen on the AP. The key mechanism of injury in the esophagus is due to electrical injury. Mucosal contact on both sides of a battery create a flow of electrical current, causing generation of sodium hydroxide in tissues and leading to local hydrolysis and liquefactive tissue injury with a significant increase in pH of the surrounding tissue [3-6]. It is also thought that the alkalotic liquefactive injury continues to occur hours after the battery has been removed [6]. In this case, as can be seen in the lateral view, the two positive poles are touching each other, with the two negative poles being in contact with the esophageal mucosa, leading to an image with the macaroon shape described, with a wider middle section, a small line of separation between the two batteries, and a smaller diameter at the outside edge [Figure 2].
ACCEPTED MANUSCRIPT The largest study into button battery ingestion found that the most important predictors of significant complications include battery diameter of >20mm, age <4 years and ingestion of >1 battery, all present in this case [5]. 12.6% of all patients under 6 who ingest a button battery of >20mm diameter will experience a serious complication. It was also noted that clinicians missed the diagnosis of button battery ingestion in 27% of cases, and 92% of fatal presentations were unwitnessed, most in non-verbal children. It has also been found that outcomes are worsening, likely due to the increasing use of the 20mm lithium ion batteries in modern households. [5,7]
SC
RI PT
A novel aspect of this case has been the use of acetic acid to lavage the esophagus post removal of the batteries to mitigate the severity of the burn. A recent paper by Jatana et al [4] has looked into the mechanism and treatment of the esophageal injury left following the removal of a button battery. A concern with using neutralising agents has been a suggestion that this may raise the tissue temperature of the area and cause a thermal injury in the reaction. Using animal models, no significant change in temperature of esophageal tissue was seen with instillation of 0.25% acetic acid, and the pH of tissues was seen to decrease from a highly alkaline 11-12, down to a more neutral pH of 6, as well as reducing visible eschar.
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The most important factor in treating esophageal button batteries is time to diagnosis and extraction. The injury free window in which a button battery can be removed with no minimal complications is <2 hours [5, 6], and increasing severity is seen with increasing time of contact [3, 5]. In an animal model, perforation was seen in every case of a battery being in place for over 12 hours [6]. This case demonstrates the importance of a high index of suspicion for unwitnessed ingested foreign bodies in a young child who presents with choking and vomiting. The associated imaging should help guide treating physicians towards a correct diagnosis. An important adjunct treatment method with 0.25% acetic acid lavage to neutralise the mucosal alkalotic injury has been demonstrated in this case to be safe and potentially effective in reducing local and long term complications. This has significant implications for treatment of ingested, inhaled or nasal impacted button batteries.
EP
Patient consent: Formal written consent was obtained from the child’s parents to publish this case report, including consent for publication of all imaging studies and intraoperative photographs and videos.
AC C
Funding: No funding or grant support. Authorship: All authors attest that they meet the current ICMJE criteria for Authorship. Conflict of interest: The following authors have no financial disclosures: EL, EL, NM, RM, JH REFERENCES 1. Munoz, JC. Foreign Body Ingestion. BMJ Best Practice. 2017. 2. Pugmire, BS, Lim, R and Avery, LL. Review of ingested and aspirated foreign bodies in children and their clinical significance for radiologists. Radiographics. 2015; 35(5), 1528-38. 3. Sinclair K and Hill ID. Button and cylindrical battery ingestion: Clinical features, diagnosis and initial management. UpToDate. 2017
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4. Jatana, KR, Rhoades, K, Milkovich, S and Jacobs, IN. Basic mechanism of button battery ingestion injuries and novel mitigation strategies after diagnosis and removal. The Laryngoscope. 2017; 127(6), 1276-82. 5. Litovitz, T, Whitaker, N, Clark, L, White, NC and Marsolek, M. Emerging battery-ingestion hazard: clinical implications. Pediatrics. 2010; 125(6), 1168-77. 6. Völker, J, Völker, C, Schendzielorz, P, Schraven, SP, Radeloff, A, Mlynski, R, Hagen, R and Rak, K. Pathophysiology of esophageal impairment due to button battery ingestion. International journal of pediatric otorhinolaryngology. 2017; 100, 77-85. 7. Litovitz, T, Whitaker, N and Clark, L. Preventing battery ingestions: an analysis of 8648 cases. Pediatrics. 2010; 125(6), 1178-83.
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Figure 1: AP view of a neck and chest, demonstrating an impacted button battery lodged at the cervical thoracic junction at the level of medial clavicles.
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Figure 2: Lateral view of neck and thoracic inlet, demonstrating the “macaroon sign” of two parallel button batteries
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Figure 3: Rigid oesophagoscopy following removal of both button batteries demonstrating circumferential esophageal burns, pre and post irrigation with acetic acid. Still image from video
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Figure 4: The batteries retrieved from the patient. Corrosion can be seen on the surface of both, along with the identifying marks.
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Figure 5: Contrast study at day 7 post ingestion, showing no contrast leakage or stenosis
ACCEPTED MANUSCRIPT
Highlights
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Button battery ingestion causes significant morbidity and mortality in children, and an impacted button battery is a time critical emergency The most important predictors of significant complications include battery diameter of >20mm, age <4 years and ingestion of >1 battery Identification on x-ray is key and the cardinal signs on imaging include a double ring in an AP view, and a bilaminar appearance in a lateral view A novel form of treatment is irrigation with acetic acid which has shown promise in animal studies and which was used in this case to good effect
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ACCEPTED MANUSCRIPT
Double button battery ingestion – the “macaroon” sign
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This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declarations of interest: none