A 5-year-old girl presents to the ENT clinic 3 days after accidental ingestion of a button battery (diameter 13 mm). She has mild dysphagia and drooling but no stridor or respiratory distress. Neck X-ray (AP and lateral) shows a round radiopaque object at the level of the cervical oesophagus, just above the thoracic inlet. The parents report no vomiting or chest pain. Vital signs are stable with SpO₂ 98% on room air. What is the most appropriate next step in management?

Explanation

## Button Battery Ingestion: Urgent Removal Imperative ### Clinical Context This child has a **button battery lodged in the cervical oesophagus** (confirmed on imaging). Button batteries pose a unique and **life-threatening risk** due to electrochemical burns, not mechanical obstruction alone. ### Why Button Batteries Are Different **Key Point:** Button batteries cause **chemical burns** through: 1. **Electrochemical reaction** — generates hydroxide ions at the negative pole 2. **Thermal injury** — local heat generation 3. **Tissue necrosis** — full-thickness burns within **2–4 hours** of contact 4. **Perforation risk** — oesophageal perforation, mediastinitis, aortic erosion, death **High-Yield:** The **2-hour rule**: Button batteries lodged in the oesophagus must be removed **within 2 hours** to prevent catastrophic perforation. Delay beyond this window dramatically increases morbidity and mortality. ### Imaging Findings Requiring Urgent Removal - Radiopaque object (button battery) on X-ray ✓ - Cervical or thoracic oesophagus location ✓ - Any duration of contact > 2 hours → **EMERGENT removal** ### Management Algorithm ```mermaid flowchart TD A[Button battery ingestion]:::outcome --> B{Confirmed on imaging?}:::decision B -->|Yes| C{Location?}:::decision C -->|Oesophagus| D[URGENT endoscopy within 2 hours]:::urgent C -->|Stomach/beyond| E{Symptoms or battery type?}:::decision E -->|Large battery or symptoms| F[Endoscopy within 24 hours]:::action E -->|Small battery, asymptomatic| G[Observe, serial X-rays]:::action D --> H[Remove under direct visualization]:::action H --> I[Assess for perforation]:::action I --> J[Admit for monitoring]:::action ``` ### Why NOT Observation or Medical Management? **Warning:** Expectant management is **contraindicated** for oesophageal button batteries: - ~~Glucagon or metoclopramide~~ — do NOT promote passage; they delay removal and increase burn depth - ~~Spontaneous passage~~ — battery will not pass; it will perforate - ~~Delayed endoscopy~~ — every hour increases risk of full-thickness necrosis **Clinical Pearl:** Oesophageal button batteries have caused: - Oesophageal perforation - Mediastinitis - Aortic erosion and fatal haemorrhage - Tracheal fistula All within 4–6 hours of ingestion. ### Correct Management **Rigid oesophagoscopy** (or flexible endoscopy if rigid unavailable) **under general anaesthesia** with: 1. Direct visualization of battery 2. Gentle removal with appropriate instrumentation 3. Assessment of mucosal injury (erythema, ulceration, perforation) 4. Post-removal imaging (chest X-ray) to exclude perforation 5. Admission for monitoring (risk of delayed perforation) [cite:American Academy of Pediatrics, Button Battery Ingestion Guideline 2023; Cummings Otolaryngology 6e Ch 197]