Airway Complications Resulting From Pediatric Esophageal Button Battery Impaction: JAMA

Severe complications of esophageal BB impaction are increasing; however, they remain rare, and therefore gaining experience in recognizing and managing these problems is important. Investigations have revealed that more than 90% of serious outcomes from BB ingestion in children were due to larger (20 mm in diameter), more powerful lithium batteries and that children younger than 5 years are at greater risk.

Animal studies have shown that injuries from BB ingestion are caustic, secondary to the rapid accumulation of hydroxide free radicals, which causes penetrating liquefactive necrosis in as little as 2 hours. This research has led to potentially revolutionary mitigation and neutralization strategies. However, because esophageal BB impactions are commonly unwitnessed and rarely present with obvious symptoms, such as hemoptysis or respiratory distress, prolonged impaction times leading to serious injury are likely to remain problematic. Furthermore, many major complications have been shown to present weeks to months after BB removal. Finally, although severe complications of esophageal BB impaction are increasing, they remain rare, and so gaining substantial experience with recognizing and managing these problems in any single center is unlikely.

The objective of the present study by Philteos et al was to analyze airway injuries after BB ingestion to raise awareness, highlight management strategies, and develop protocols for prevention.

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

A total of 195 patients were included in the analysis; 95 were male. The mean (SD) age at BB ingestion was 17.8 (10.2) months. The mean (SD) time from BB ingestion to removal was 5.8 (9.0) days. The 2 most common airway sequelae observed in our series were 155 tracheoesophageal fistulae and 16 unilateral vocal cord paralyses. Twenty three children had bilateral vocal cord paralysis. The mean (SD) duration of ingestion leading to vocal cord paralysis was shorter than that of the general cohort (17.8 [22.5] hours vs 138.7 [216.7] hours, respectively). Children presenting with airway symptoms were likely to have a subsequent tracheoesophageal fistula or vocal cord paralysis.

Esophageal BB impactions are a significant danger for children worldwide. The direct apposition of the trachea with the esophagus and recurrent laryngeal nerves puts young children at risk of airway injury secondary to liquefactive necrosis induced by BB impaction. Despite recent efforts stressing the importance of prompt recognition, removal, and strategies to reduce injury, moderate and severe injuries are increasing. Authors identified 195 children with airway complications after BB ingestion to help better understand the presentation, management, and outcomes of this devastating injury.

Young children were at highest risk of airway complications after BB ingestion. Children younger than 6 years comprised 62.5% of BB injuries, with the greatest frequency occurring in those aged 1 to 3 years. In this review, 90% of children with airway injury after BB ingestion were younger than 5 years, and 70% were younger than 2 years; BB ingestions occurred even among children as young as 1 week, which is below the age one might expect children to be able to reach and place objects in their mouth.

Most BB impactions causing airway injury were in the proximal esophagus, and previous work has shown that BBs are most likely to be impacted at that level. Button batteries located in the proximal esophagus with the negative pole facing anteriorly are believed to be more likely to cause vascular injuries, TEF, and vocal cord paralysis, given the anatomic relationship of these structures. Although BBs 20 mm or larger are the most likely to become impacted, those of all sizes have the potential to cause airway injuries. In this study, the smallest reported BB was only 10 mm in diameter.

In general, any child presenting to the emergency department with symptoms consistent with foreign body ingestion should have both anteroposterior and lateral radiographs taken of the chest and airway to help differentiate the relatively ubiquitous coin ingestion from BB ingestions. Careful examination of these radiographs for the halo sign, as well as the step-off between the positive and negative nodes of BBs, should be performed. Furthermore, the radiograph may help to determine the size of the battery and its location for surgical planning and risk stratification. Although there was insufficient documentation to comment on anode orientation, our review confirmed that most children who developed TEF (51 of 89 [57%]) or vocal cord paralysis (29 of 35 [83%]) had a BB impaction in the proximal esophagus.

Tracheoesophageal fistula was the most common injury, with most patients requiring surgical management. Spontaneous closure of TEFs was found to occur in younger children compared with those who required surgical repair.

Thirty-nine children had vocal cord paralysis after BB ingestion and had a significantly shorter duration of BB impaction compared with that in the overall cohort of airway injuries. This suggests that serious airway injury can occur in the absence of perforation even after short periods of BB exposure. All children, particularly those younger than 5 years or with a BB in the proximalesophageal position, should undergo awake flexible nasolaryngoscopy to assess vocal fold dysfunction before hospital discharge. Study findings indicate that vocal cord paralysis can occur even after very short exposures and serve to stress the importance of preventive strategies to avoid BB ingestions and the institution of mitigation BB strategies when immediate removal is not possible.

One of the challenges in the prompt identification of BB ingestion is the nonspecific nature of the presenting symptoms. Moreover, given the possibility of a long delay in the presentation of TEF, caregivers may not volunteer a history of BB ingestion when children present with new airway symptoms. Authors therefore recommend that a history of BB removal be considered for children presenting with new airway symptoms and that, if there is one, these patients undergo prompt airway evaluation with direct laryngoscopy, bronchoscopy, or esophagoscopy.

Button batteries can cause visible injury within 15 minutes if lodged in the esophagus, and serious injury can occur within 2 hours. Mitigation strategies, including administration of honey or sucralfate, may help prevent these injuries; however, removal should never be delayed. Similarly, neutralization strategies with the administration of 0.25% acetic acid may reduce ongoing injury after removal of the BB. Although focus on airway injuries may have skewed the duration of exposures in cohort of patients, the time to BB removal is too long, and institutions need to focus on reducing it.

Airway injuries are a severe consequence of BB ingestion, occurring more often in younger children. Tracheoesophageal fistulae and vocal fold paralyses were the 2 most common airway injuries, often requiring tracheostomy. Vocal cord injuries can occur even after a very short duration of exposure, reinforcing the importance of otolaryngologic follow-up for these children. Prioritization of timely BB removal is essential to decrease the devastating consequences of these injuries.

Source: Justine Philteos; Adrian L. James; Evan J. Propst; JAMA Otolaryngology–Head & Neck Surgery July 2022 Volume 148, Number 7 doi:10.1001/jamaoto.2022.0848