|Year : 2013 | Volume
| Issue : 1 | Page : 22-25
The saga of a neglected foreign body in esophagus
A Ravikumar1, Prasanna S Kumar1, L Somu1, M. N. Thowfeeka1, S Balagopal2
1 Department of Otolaryngology and Head and Neck Surgery, Sri Ramachandra Medical College and Research Institute, Porur, Chennai, Tamil Nadu, India
2 Department of Paediatric Surgery, Sri Ramachandra Medical College and Research Institute, Porur, Chennai, Tamil Nadu, India
|Date of Web Publication||24-Sep-2013|
Prasanna S Kumar
Department of Otolaryngology and Head and Neck Surgery, Sri Ramachandra Medical College and Research Institute, Porur, Chennai 600 116, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
An ingested foreign body lodged in the esophagus is common in children. Button batteries impacted in the esophagus need early diagnosis and intervention to avoid complication. We report a case of neglected button battery impacted in the upper esophagus in a 15-month-old female child. The problems encountered during the course of management have been discussed along with the review of the literature. Button battery ingestions in children need to be considered as an emergency and prompt endoscopic removal should be advocated. Rigid esophagoscopy is the gold standard technique of removing esophageal foreign bodies. Complication must be anticipated and managed at the earliest.
Keywords: Button battery ingestion, corrosive injury of esophagus, tracheo-esophageal fistula
|How to cite this article:|
Ravikumar A, Kumar PS, Somu L, Thowfeeka M, Balagopal S. The saga of a neglected foreign body in esophagus. J Laryngol Voice 2013;3:22-5
| Introduction|| |
In the natural process of development, infants start mouthing objects by 6 months. The curious and innovative toddlers enjoy and explore the objects around them by way of mouthing. Due to this reason the peak incidence of foreign body (FB) ingestion occurs between 6 months and 3 years of age. 
In USA about 100,000 cases of esophageal foreign bodies are reported every year, out of which 80-90% pass spontaneously through the upper gastrointestinal tract.  In western literature, case reports of ingested foreign bodies are predominantly "coins" whereas the reports from India are usually food particles such as fish and chicken bones. 
Increased usage of electronic gadgets at home that are powered by button/disc batteries like calculators, watches, electronic toys, etc., have increased the frequency of button battery ingestions in the recent decades. ,, Most of them have an uneventful course. About 3% of them are larger batteries usually of size 20-23 mm and have more chances of getting impacted in a child's small esophagus leading to serious complications such as tracheo-esophageal fistula, ,,,] stenosis,  burns, , esophageal perforation ,, mediastinitis, vocal cord palsy,  damage to blood vessels including aorto-esophageal fistula and death. 
| Case Report|| |
A 15-month-old female baby was referred to us with the diagnosis of FB esophagus. The child's father gave a history of persistent cough, fever, regurgitation and refusal of feeds for the duration of 1 week. She was treated by Pediatricians for upper respiratory tract infection and had visited two hospitals in that time period. Since symptoms did not subside, chest X-ray had been taken which showed a round, radio-opaque FB in the prevertebral region at the level of C7-T1 vertebra behind the airway. She was referred to us for further management. The parents didn't give any definite history of FB ingestion. On further questioning, her father told us about the button batteries, which were left over the television set on the day of the incident.
At presentation, she was irritable, crying with drooling of saliva. She was febrile (104°), with tachycardia and tachypnea. She had elevated total white blood cell count of 34,000 cells/cu mm. Initially, she was admitted in pediatric intensive care unit and was started on intravenous antibiotics and supportive therapy. Posteroanterior (PA) and lateral chest radiographs were carried out, which revealed a round, radio-opaque FB lying in a coronal plane at the level of C7-T1. It also had a "double rim" at the periphery in Antero-posterior view and "step off" in the lateral view [Figure 1] a and b. The peripheries of the FB showed irregularities, suggestive of a leaking button battery.
|Figure 1: A round, radio-opaque foreign body seen at the level of C7-T1 in the prevertebral region behind the airway. A "double density" in the AP view (a) and "step off" in the lateral view (b) can be noted|
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She underwent emergency rigid esophagoscopy and removal of FB under general anesthesia. It was seen impacted in an oblique plane in the upper esophagus just distal to cricopharynx. Check esophagoscopy showed a white ulcerated mucosa with the surrounding area of inflammation in the anterior wall of the esophagus at the site of FB impaction. The removed FB was a CR2025 Li-Mn 3V disc battery [Figure 2], where Li-Mn represents lithium-manganese dioxide composition of the positive terminal. The battery was 20 mm in diameter and 2.5 mm in thickness. After removal, a nasogastric tube (NGT) was placed in situ.
She was kept nil per oral post-operatively. The NGT was accidently pulled out by the child on first post-operative day. She was started on sips of water orally on third post-operative day. As she had cough on drinking sips of water, she was kept nil per oral. On the same day, the child had tachypnea and was drowsy. She developed abdominal distension and had intermittent fever spikes. Further evaluation was suggestive of electrolyte disturbances with hypokalemia and hypomagnesemia. Repeat X-ray chest and abdomen showed distended small and large bowel loops [Figure 3] a. Computed tomography (CT) neck showed a 2 mm fistulous communication between the trachea and esophagus at the level of C7-T1 [Figure 3] b. Fluoroscopy assisted gastrograffin swallow study was performed, which showed leak of contrast into trachea suggestive of tracheo-esophageal fistula [Figure 3] c.
|Figure 3: (a) X-ray chest and abdomen which showed distended large and small bowel loops during the post-operative period. (b) A 2 mm communication between the trachea and esophagus at the level of C7-T1. (c) Fluroscopy assisted gastrograffin swallow study carried out after removal of foreign body demonstrated leak of contrast into trachea|
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Joint consultations with Pediatricians, Pediatric Surgeons and Cardiothoracic Surgeons were taken and it was decided to manage her conservatively for 8 weeks. She was on NGT feeds and also had a steady weight gain at discharge 1 week later.
On review after 8 weeks, CT Neck with 3D reconstruction of the trachea and esophagus along with fluoroscopy assisted gastrografin swallow study were done, which revealed persistence of fistula. A decision for surgical repair of tracheo-esophageal fistula was taken. Since the site of the trachea-esophageal fistula was at the thoracic inlet we felt that the best approach to the fistula would be a lateral cervical incision and partial median sternotomy, we also planned for a feeding jejunostomy as a prophylaxis to keep the child nil orally and also to prevent recurrence after repair. Hence, we proceeded with a feeding jejunostomy and lateral cervical incision with partial median sternotomy [Figure 4] a and b. Innominate vessels were identified and retracted. Tracheo-esophageal fistula was identified at the cervico-thoracic inlet and divided. Primary suturing of the trachea and esophagus with allograft pericardial interposition was done. Post-operative period was uneventful. After 4 weeks, CT neck and fluoroscopy assisted gastrograffin swallow study was repeated, which showed no evidence of a leak. She tolerated oral feeds. Hence, closure of feeding jejunostomy was done. Patient has been followed-up for 6 months now. She is asymptomatic and has gained 2 kg weight.
|Figure 4: (a) Trache-esophageal fistula (white arrow) identified at the thoracic inlet by the anterior cervical approach with limited sternal split. Trachea (black arrow) and esophagus (yellow arrow) is also seen. (b) Homologous pericardial interposition done after primary suturing of the trachea and esophagus|
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| Discussion|| |
Alkaline button batteries account for lesser than 2% of foreign bodies ingested by children. , Yardeni et al. in their retrospective analysis of button battery ingestions have reported that the peak incidence occurred under the age of 2 years and that the gender distribution was equal, unlike the male predominance reported by others.  About 3% of batteries may get impacted in the esophagus and those are large diameter batteries more than 20 mm. , Around 70% of foreign bodies get impacted at the upper end of the esophagus. The remaining impactions occur either at the mid esophagus where the aortic arch crosses (15%) or at the level of the lower esophageal sphincter (15%). In our case, the FB was impacted in the upper esophagus.
Button batteries should be differentiated from other esophageal foreign bodies due to their potential to cause catastrophic complications, such as esophageal burns, , perforation, ,, stenosis,  tracheo-esophageal fistula. ,,,] Blatnik et al. in 1977 reported the first case of esophageal complication in which the battery eroded through the inferior thyroid vessels causing death.  Maves et al. in their experimental study reported that mucosal damage can occur as early as 1 h that progressed to transmural necrosis within 4 h. They also reported tracheo-esophageal fistula to develop as early as 20 h.  Others have reported esophageal perforation to occur as early as 6 h. , Studley et al. in 1990 reported aortic arch erosion secondary to impacted button battery in the esophagus leading to death. 
Button batteries consist of zinc or lithium anode and a cathode made of any one of the oxides of manganese, silver or mercury. They are separated by a disc containing strong alkali or an organic solution. All these components of the battery are encased in a case made of either steel or nickel. ,
The factors, which contribute to tissue injuries caused by batteries include:
- Leakage of [OH] ions, which react with the mucosal proteins leading to liquefaction, necrosis and saponification of lipid membranes
- Absorption of toxic substances: Though rare, broken or fragmented batteries may lead to absorption of heavy metals. Mercury batteries are more likely to fragment than others. Mallon et al. reported a case of lithium battery ingestion in a 5-year-old boy in whom the serum lithium concentration was raised (0.7 mEq/L) 
- Electrical discharge: The flow of electric current to the tissue occurs through the negative pole causing local hydrolysis, hydroxide accumulation and corrosive tissue injury. In previous studies, lithium cells were associated with most severe outcomes as they contain higher voltage (3V) and capacitance compared with other button batteries. Likewise charged batteries are associated with severe esophageal injuries
- Pressure necrosis caused by the presence of battery in the esophagus. ,,,,,,,
The extent of damage caused depends upon:
- Diameter of battery: In our case, the larger diameter of the lithium battery (20 mm) resulted in esophageal impaction
- Chemical contents of the battery such as manganese, silver, mercury, lithium and zinc
- Position of anode side of battery against the esophageal wall and,
- Time period for which the battery is present in the esophagus. ,,
Delayed and missed diagnosis is not infrequent as in our case. Clinical presentation vary from asymptomatic patients and those presenting with early non-specific symptoms mimicking respiratory tract infections, dysphagia, drooling of saliva, black flecks in the saliva, chest pain, epigastric pain, abdominal pain, nausea, vomiting, hemetemesis, diarrhea to those with severe respiratory distress. On radiography, batteries can be distinguished from coin by the presence of "double density" on a PA view and a "step-off" at the separation between the anode and cathode on lateral view. ,
Emergency endoscopy with FB removal followed by assessment of impaction site in anticipation of complications is mandatory. ,, Excessive tracheal secretions, choking, persistent cough or cyanosis during feeding should arise suspicion of tracheo-esophageal fistula.  Fluroscopy assisted gastrograffin swallow study and 3D multislice CT are useful radiological investigations to monitor the progress of tracheo-esophageal fistula. Virtual bronchoscopy is another non-invasive technique, which provides information on the mucosal surfaces of hollow viscera and provides 3D realistic views of tracheo-esophageal fistula. ,
Surgical treatment of acquired tracheo-esophageal fistula is more difficult than congenital anomaly due to surrounding inflammation. , Possibility of recurrent fistula is also high in primary repair of tracheo-esophageal fistula.  Conservative management should be tried to allow spontaneous closure and for the inflammation to subside at the impaction site. Conservative management includes total parenteral nutrition, NGT insertion or gastrostomy/jejunostomy depending upon the condition of the patient along with anti-inflammatory and anti-reflux medications. , Kimball et al. in their review of disc battery ingestions have reported spontaneous closure of tracheo-esophageal fistula in three out of four cases with delayed diagnosis of disc battery ingestions.  In the same year, Biswas et al. have also reported successful closure of tracheo-esophageal fistula secondary to button battery ingestion following conservative management. 
In our case, active intervention was deferred at the time of diagnosis of tracheo-esophageal fistula for the following reasons:
- To wait for spontaneous closure as the fistula was small
- For the inflammation to subside at the site of FB impaction
- Surgical approach to the fistula was difficult as it was situated at the level of the thoracic inlet.
In case of failed conservative management, thoracotomy and closure of fistula should be considered. ,,, Acquired tracheo-esophageal fistula caused by foreign bodies are usually located at the level of the thoracic inlet and makes direct surgical approach difficult. A cervical approach with partial median sternotomy can be used to access the fistula more easily.  Szold et al. recommended cervical oesophagostomy and gastrostomy and a delayed colon interposition in severe respiratory insult.  Regular follow-up over a year to rule out delayed complications like stricture, recurrence is mandatory. 
| Conclusion|| |
FB should be suspected in children less than 3 years with upper respiratory tract infection not responding to medical treatment. Button battery ingestions in children should be considered as a medical emergency and prompt endoscopic removal should be performed. Rigid esophagoscopy is the gold standard technique of removing esophageal foreign bodies. After removal of FB, meticulous endoscopic examination of impaction site is important.
Conservative management can be tried for initial management for acquired tracheo-esophageal fistula. Early recognition of complications and a multidisciplinary approach is necessary for a successful outcome. The anterior cervical approach with limited sternal split provides excellent access to tracheo-esophageal fistula at the thoracic inlet. We followed a similar protocol and finally achieved a successful result.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]