The hazards of impacted alkaline battery in the nose.

A foreign body in the nose is a common referral dealt by the otolaryngologist on daily basis. Here we report a case of a 5-year-old girl who was referred from a primary care center with complaints of left nasal blockage and epistaxis along with foul smelling brownish discharge for 1-day duration. Nasal endoscopic examination of the left side of the nose revealed an impacted button battery at the cartilaginous portion of the nasal septum.

Introduction

A foreign body embedded in the nose can be hazardous especially when the foreign body is able to generate a chemical reaction over the contact surface such as a button battery. If it is not treated early, it could result in various complications such as bleeding, infection, and mucosal breach. Therefore, urgent referral is crucial to prevent unwanted complications.

Case Report

A 5-year-old girl was brought to the primary care center by her mother with complaints of left-sided nasal pain with epistaxis along with foul smelling brownish discharge for 1-day duration. The mother gives history of her child inserting a foreign object in the nose 1 day ago while she was playing outside the house with other children. On examination, the child had high-grade fever and foul smelling brownish fluid discharging from the left nostril. There was also swelling and redness noted over the left nostril extending to the left cheek. Anterior rhinoscopy examination revealed a round metallic looking object embedded in the anterior aspect of the left nasal cavity. An X-ray of the lateral view of the face was done which revealed a round looking foreign object embedded in the left nasal cavity [Figure 1]. The patient was then referred urgently to the Department of Otolaryngology, Hospital Universiti Sains Malaysia, for further management after the attempt of removal of the foreign body failed. On examination, there was swelling around the left alar region of the nose which was extending to the left cheek. The skin in that region appeared inflammed. The nose was examined using an endoscope, which revealed a button battery embedded in the cartilaginous portion of the nasal septum in the left nasal cavity. The mucoperichondrium of the septal cartilage appeared eroded. The child was admitted with a diagnosis of button battery in the left nostril with left facial cellulitis. The button battery was removed under general anesthesia. The mucosa of the septal cartilage was eroded and filled with crust. However, there was no perforation noted. A thorough irrigation of the internal nose was carried out using normal saline. The child was started with intravenous co-amoxiclav along with analgesia. The swelling of the nose and facial region subsided within 3 days. A repeated endoscopic examination of the nose showed that the affected part of the cartilaginous portion of the nasal septum had subsequently improved. She was then discharged home with oral co-amoxiclav. During her first follow-up 2 weeks later, a repeated nasal endoscopic examination was done which showed a well-healed nasal mucosa of the affected part of the septal cartilage.

Figure 1

X-ray of the face showing a foreign body in the nose

Discussion

The majority of foreign bodies in the nose are seen in children between the age of 2 and 5 years. This is expected as children in this particular age group are curious and tend to insert objects which they find around their environment into their nostrils. The most frequent foreign bodies are beads, food particles, button batteries, toys, and household items. The presence of a foreign body in the nose usually may present with a unilateral nasal discharge, pain, and nasal obstruction. Sometimes the encounter of a foreign body can be a coincidental finding following an imaging of the head and neck region which is attained secondary to symptoms which is not related to the foreign body itself.[1]

The usage of button batteries has become more common in recent years to power small electronic devices such as hearing aids, watches, toys, remote control devices, and other items. The shiny properties of the button batteries can attract the children to play and aspirate or lodge it into aerodigestive tract. There are different types of button battery invented such as alkaline, silver, zinc, manganese, lithium, and mercury. The battery contains anode part usually zinc or lithium, cathode part, and is separated by electrolyte-soaked separator such as sodium hydroxide or potassium hydroxide to facilitate electrochemical reaction.[2] The increase in button battery incidents is due to increase in marketing and use of lithium coin especially the 20-mm diameter.[3] There are a few proposed mechanisms of injury caused by button batteries. First, leakage of battery contents when seal of plastic and the layer separating the anode and cathode mixtures becomes eroded. Second, production of local currents where it can discharge current through surrounding tissue when battery is in contact with nasal mucosa. Third, direct current burns resulting from direct currents flowing through the tissue. Fourth, pressure ischemic necrosis of the surrounding tissue when battery lodges in tight nasal cavities. Finally, generation of hydroxide through electrolysis.[45] Based on the study, battery-related emergency department (ED) visits by US children using nationally representative sample shows that battery ingestion accounted for (76.6%) of ED visits, followed by nasal cavity insertion (10.2%), mouth exposure (7.5%), and ear canal insertion (5.7%), and the majority of cases on nasal cavity insertion was observed among children age ≤5 years, with a mean age of 3.3 years.[6]

The damage caused by button batteries can be very fast, distressing and causing long-term effects. It has been reported that time of impaction of button battery ranging as little as 3–6 h may produce mucosal turbinate and septal ulceration.[7] If there is no prompt taken, inferior meatus ulceration, saddle deformities, chondritis, atrophic rhinitis, alar collapse, septal perforation, and nasal/choanal stenosis may result.[18] In this case, the child who inserted button in nasal cavity triggered the local mucosal irritation and the active battery generated current resulting in thermal burns and damaged the nasal mucosa causing intense local tissue. Besides that, the impacted metal leads also leads to local congestion.[9] Hence, the patient presented with nasal discharge, crusting, mucosa edema, and inflammation. However, due to prompt treatment, she was able to avoid complication of septal perforation.

Management usually depends on detailed history taking, physical examination, radiological and blood investigation, and diagnostic nasal endoscopy. In this case, the witness was able to identify symptoms such as nasal irritation, pain in the nose, foul smelling profuse brownish nasal discharge, and epistaxis. It is very important for parents to observe their children properly for early detection to reduce the chances of complication such as septal perforation especially toxic shock syndrome as it is fatal. It is also important for emergency physician to rule out the possibility of any foreign body being button battery as it is often misdiagnosed as a coin, thus resulting in unnecessary delay in removal.[2] The placed button batteries may be removed promptly by the emergency physician in outpatient setting like in this case. However, if the removal failed, the button battery removal can be done under general anesthesia with endoscopic guidance.[9] Intravenous antibiotic and oral inflammatory drugs are given in patients with secondary infection, mucosal damage, congestion, and granulation. After that, patients are required for proper follow-up to watch out for any delayed sequele.[9]

Conclusion

Button batteries are hazardous materials as their properties can cause harm to our body if in contact with mucosa and cause long-term complications. This case shows the importance of early detection by parent and early referral for prompt removal of button battery as the key management in this patient. It is very important to suspect foreign body insertion like button battery if patient presented with foul smelling discharge. Empirical treatment such as antibiotic is also given to prevent secondary infection. Besides that, the importance of long-term and regular follow-up needs to be stressed to patients. Hence, to prevent this incident, parents and child care providers need to be informed of the hazard of these button batteries and appropriate measures should be taken.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.