Overview
Definition:
A button battery lodged in the pediatric nasal cavity is a medical emergency requiring prompt identification and removal due to the potential for severe mucosal damage, liquefaction necrosis, and perforation caused by electrical current and alkaline hydrolysis.
Epidemiology:
More common in younger children (ages 1-5 years) due to exploratory behaviors
Prevalence data is limited but is a recognized cause of pediatric nasal foreign bodies presenting to emergency departments.
Clinical Significance:
Early and effective removal is crucial to prevent irreversible damage to the nasal septum, turbinates, and surrounding structures
Delayed recognition can lead to chronic sinusitis, septal perforation, synechiae formation, and even intracranial complications in rare, severe cases.
Clinical Presentation
Symptoms:
Sudden onset nasal obstruction or blockage
Epistaxis, often unilateral
Nasal discharge, which may be purulent or malodorous
Pain or discomfort in the nose
Decreased or absent sense of smell unilaterally
Absence of symptoms is possible if the battery is small and anterior.
Signs:
Visible foreign body in the nasal cavity on anterior rhinoscopy
Mucosal edema, erythema, and ulceration around the foreign body
Possible purulent discharge or crusting
Septal deviation or erosion may be evident
Signs of impaction or fixation within the nasal passage.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on history of potential exposure and visualization of the foreign body on nasal endoscopy or anterior rhinoscopy
Absence of symptoms does not rule out the presence of a nasal foreign body.
Diagnostic Approach
History Taking:
Inquire about known or suspected ingestion/aspiration of small disc-shaped batteries
Ask about recent onset of nasal symptoms, particularly unilateral obstruction, epistaxis, or foul-smelling discharge
Note any history of trauma or prior nasal procedures
Ascertain the type of battery if possible (e.g., from remote controls, small toys, watches).
Physical Examination:
Perform a thorough anterior rhinoscopy to visualize the nasal cavity
If the foreign body is not readily visible, proceed to nasal endoscopy under appropriate sedation or anesthesia
Assess for signs of mucosal injury, inflammation, and bleeding
Evaluate for any signs of airway compromise.
Investigations:
Plain radiographs (lateral and anteroposterior views) of the nasal passages can confirm the presence and location of a radiopaque foreign body, although batteries may not always be clearly visualized depending on the angle
CT scan is usually not required for initial diagnosis but may be useful if complications are suspected or removal is difficult
No specific laboratory investigations are typically needed for diagnosis.
Differential Diagnosis:
Other nasal foreign bodies (e.g., beads, plastic fragments, food items)
Nasal polyps
Nasal tumors
Acute or chronic sinusitis with purulent discharge
Septal hematoma or abscess.
Management
Initial Management:
Immediate referral to an otolaryngologist or emergency physician skilled in pediatric airway management
Airway assessment is paramount
Do NOT attempt removal with blunt instruments or by forcefully blowing the child's nose, as this can cause further injury or displace the battery deeper.
Medical Management:
Topical vasoconstrictors (e.g., oxymetazoline) may be used cautiously to reduce mucosal edema
If there is significant inflammation or suspected secondary infection, a short course of topical or oral antibiotics may be considered after removal
Pain management with appropriate analgesics.
Surgical Management:
Emergent removal is indicated
Nasal endoscopy is the preferred method, allowing for direct visualization and precise removal using specialized grasping instruments (e.g., crocodile forceps, bayonet forceps) or suction under magnification
If the battery is lodged deeply or removal is challenging, a formal otolaryngology consultation is essential
In cases of severe mucosal damage or perforation, surgical intervention to debride necrotic tissue or repair the septum may be necessary
Adequate analgesia and sedation/anesthesia are crucial for a safe procedure
The use of a vasoconstrictive agent (e.g., topical cocaine or epinephrine) applied to the nasal mucosa can aid in visualization and reduce bleeding.
Supportive Care:
Post-removal care involves close monitoring for signs of bleeding, infection, or airway compromise
Nasal saline irrigations can help maintain hygiene
Follow-up with ENT is recommended to assess for healing and long-term complications such as synechiae formation
Provide emotional support to the child and parents.
Complications
Early Complications:
Mucosal burns and ulceration
Nasal septum perforation
Hemorrhage
Septal hematoma
Trismus
Pain
Infection.
Late Complications:
Synechiae formation (nasal adhesions)
Chronic sinusitis
Saddle nose deformity
Nasal airway obstruction
Osteomyelitis in rare, severe cases
Foreign body aspiration during removal attempt.
Prevention Strategies:
Safe storage of button battery-containing devices out of reach of young children
Use of devices with secure battery compartments
Public awareness campaigns regarding the dangers of button batteries.
Prognosis
Factors Affecting Prognosis:
Timeliness of removal
Size and location of the battery
Extent of initial mucosal damage
Presence of associated comorbidities
Expertise of the managing physician.
Outcomes:
With prompt and appropriate removal, the prognosis is generally excellent, with minimal long-term sequelae
Severe mucosal damage may lead to more prolonged healing and potential for complications like synechiae or septal perforation.
Follow Up:
Regular follow-up appointments with an otolaryngologist are recommended, typically within 1-2 weeks post-removal, to monitor healing, assess for complications like synechiae, and ensure adequate nasal airflow
Further follow-up may be required depending on the severity of initial injury.
Key Points
Exam Focus:
Button batteries in the nose are an emergent pediatric ENT issue
Recognize signs of mucosal damage and potential perforation
Nasal endoscopy is the gold standard for removal
Prioritize airway and secure removal.
Clinical Pearls:
Always suspect a button battery with unilateral epistaxis/obstruction in a young child
Topical vasoconstriction is your friend for visualization
If you can't see it well or remove it easily, call ENT immediately
Do NOT attempt blind removal.
Common Mistakes:
Delaying removal
Attempting removal with inappropriate instruments
Overlooking a retained foreign body due to lack of symptoms
Insufficient anesthesia/sedation leading to patient movement and injury
Failure to consider potential for esophageal or gastric battery ingestion simultaneously.