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Clinical case: Button battery ingestion: want to learn more about it?

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Clinical case: Button battery ingestion

In this article, we describe a case of a baby who developed a bilateral vocal cord palsy after a lithium button battery ingestion!

After reviewing this case you should be able to describe the following:

  • The surgical anatomy of a tracheostomy and the conditions under which this procedure is done rather than a cricothyrotomy.
  • The structure of the larynx including its cartilages , ligaments and compartments.
  • The muscles of the larynx, including their attachments, innervation and actions in the neck. Also, the clinical aspects of damage to the nerves that innervate the muscles of the larynx.

This article is based on a case report published in the Journal "Case Reports in Surgery" in 2015, by Caroline C. Jadlowiec, Beata E. Lobel, Namita Akolkar, Michael D. Bourque, Thomas J. Devers, and David W. McFadden.

It has been modified and reviewed by Joel A. Vilensky PhD, Carlos A. Suárez-Quian PhD, Aykut Üren, MD.

Case description

Clinical exam and imaging

The patient was a 10-month-old baby girl with the complaint of stridor (noisy breathing) for the past day. The baby was not accepting food and also had drooling of saliva. A routine chest radiograph to rule out chest infection revealed a characteristic, well-delineated radio-opaque shadow in the upper part of the thoracic esophagus (Figure 1). 

Figure 1. Frontal radiograph of baby showing the foreign object in the superior mediastinum. Note that the trachea (highlighted with green) appears compressed and shifted to the right due to the presence of the battery (foreign body).

Management

A diagnosis of un-witnessed lithium button battery ingestion was made; the battery was then removed with the aid of an endoscope under general anesthesia. At the time of removal, marked charring with slough was noted in the upper esophagus.

Evolution

Postoperatively, the baby showed a dramatic improvement and was discharged on the seventh postoperative day. However, within a week of discharge, the baby again developed mild stridor upon exertion, which gradually worsened over a period of time. A pediatrician then treated the baby for tracheobronchitis, which resulted in some improvement.

However, two months after the removal of the foreign body the patient presented in the emergency department with acute stridor. An immediate tracheostomy was performed, as the physicians were unable to intubate the child. A subsequent endoscopic examination of her vocal cords revealed that the patient had bilateral vocal cord palsy (Figure 2).

Figure 2. Endoscopic view of the child’s larynx shortly after the tracheostomy. Note the paramedian position of the vocal cords.

This paresis has not improved for the last six months. The parents have been counseled that surgical treatment of the patient will likely be necessary if there is no improvement over the next six months.

Anatomical and surgical considerations

Figure 3. An overview image showing the pharyngeal mucosa and related structures.

Complications of battery ingestion

The incidence of lithium button battery ingestion has been increasing in children. Ingested lithium button batteries are associated with significant morbidity and occasional mortality if they get impacted in the esophagus or trachea . As exemplified by this case, such ingestion may cause late complications such as:

  • esophageal perforation
  • tracheoesophageal fistulas
  • exsanguination after fistulisation into major blood vessels
  • esophageal stricture
  • vocal cord palsies
  • recurrent infections

It seems likely that the baby’s initial stridor was caused by the compression of her trachea as shown by Figure 1.

Vocal cord palsy

However, even after the expeditious removal of the battery, the patient later developed bilateral vocal cord palsy. The most likely cause for the presumed delayed battery injury is generation of an external electric current that causes electrolysis of tissue fluids, generating hydroxide ions at the battery’s negative pole and the scarring of tissues. These batteries create a three-volt differential, which apparently affects body tissues significantly more severely than the older 1.5 volt small batteries.

Bilateral vocal cord palsy is a life-threatening situation that always presents with acute respiratory distress. Presumably, the nerves that control most of the laryngeal muscles , the recurrent laryngeal nerves, were scarred by the abnormal electrical activity, but some time has to elapse before the vocal cords eventually drifted to a midline position and obstructed respiration.

The treatment protocol for bilateral cord palsy requires that these cases be kept under observation for at least one year after initial airway management (tracheostomy) because spontaneous recovery does occur in such cases. Surgical correction should be considered only if the spontaneous recovery fails to occur. Surgical intervention includes restoring the airway at the vocal cords and decannulation of tracheostomy. The approach could be a conservative procedure (transverse cordotomy [cutting posterior aspect of vocal cords to open airway] and medial arytenoidectomy) or a radical procedure (total arytenoidectomy). The recurrent laryngeal nerves arise from the vagus nerves in the lower neck and pass around the subclavian artery on the right, and the arch of the aorta on the left, to ascend in the tracheoesophageal groove to enter the larynx deep to the inferior constrictor muscle (Figure 4).

Figure 4. Cadaver photograph showing the relationship of the left recurrent laryngeal nerve to the trachea and the esophagus.

Damage to these nerves results in various forms of vocal and respiratory difficulties. The respiratory difficulties result because, with the loss of neural innervation, the vocal cords drift toward a fixed paramedian position that restricts air passage through the larynx, especially if both nerves are affected. That is why the child in this case was having stridor even after removal of the battery. However, it also is possible that the child’s continued stridor was due to direct injury of the larynx, especially the cricoarytenoid joints.

Figure 5. An illustration showing the left and right recurrent laryngeal nerves.

Clinical case: Button battery ingestion: want to learn more about it?

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